20050084.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF USINESS
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PERMIT 17 F
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PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved ❑
RW Permit RagU d ❑
Street Usti Permd Reqwtud ❑
EXISTING _ PROPOSED _ Inspection Requited ❑
Sidewalk Required ❑
REQUIRED DEDICATION FT Underground ❑
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METER SIZE LINE SIZE 7FNO. OF FIXTURESPRV REQUIRED
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FIRE REVIEWED BY DATE w
STATE LICENSE NU/M�BE-R //� y/[� E/X/ypIRATIO/�D/A�TE CKE B VARIANCE OR CU SHORELINE OR ADB# INSPECTION, 't vpnt counja� Qr„�, SPA
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PROPERTY TAX ACCOUNT PARCEL N0. CA# 7�ONE lIl111�'1;11 HEIG T
WAIV fuel- urlaeng Ala ,ALLOWED PROP fj(J ROPOSED
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[3 NEW RESIDENTIAL LUMBI / MECH L T COV SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLO PROPOSED FRONT SIDE REAR FRONT LIR SIDE REAR t,
❑COMMERCIAL COMPLIANCE OR z
1:1 ADDITION
❑MIXED CHANGE OF USE z
MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
1:1❑GRADING ❑ FENCE X FT.) REMARKS
REPAIR CYDS.
❑ DEMOLISH ❑ TANK OTHER
❑ GARAGE CARPORT ❑ ROCKIERY NING WALL ❑ FIREALARM FIRE LER
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN: /IC
TYP CON NCy�frj. OCCUPANT
GROUP
NUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS LOAD
REQUIRED CI. YES
DESCRIBE WORK TO ErE DONE
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12 VALUATION
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7 kAM14 FEE Description FEE
Plan Check Slate Surcharge
HE OURCE �, LOT SLOPE% VESTED DATE
vl Building Permit City Surcharge
PLAN HECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC Grading
E DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
J SEPARATE PERMISSION.
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Engr. Review
F PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engf. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
Y EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
= ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.* ,
Recording Fee Receipt # J
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF This application Is not a permit until signed by the
THE OWNER, I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC. CALL Building Official or his/her Deputy and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged In space provided.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATIO NCE AND RCW 18:27. OFP!QtAL aIGNAT EE E
SIG URE (OWNS DATE GNED 425 �, �%
/ - L / G—,
`� 771=0220 RELEASED / DATE
ATTENTION EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL - FILE YELLOW - INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110, PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD = YOU ARE MAKING 4 COPIES
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