20050096.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
W MAILING ADDRESS
z
0 7127L
CITY ZIP TELEPHONE
NAME
PERMIT EXPIRES 14PERMIT
NUMBERI17
JOB (SUITE/APT#
ADDRESS � 1 1 e�
PAT NAMEISUB DIVISION NO. LOT NO, LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved
RW Permit Required
Sheet use Permit Required
EXISTING PROPOSED Inspection Requited
Sidewalk Requited
REQUIRED DEDICATION FT underground
Witing requited
METERWE PR x_14 9PMTI N k ft OfftkT S PRV REQUIRED
YES 0 NO
PROPERTY LINE
WATER METER TO BE REMOVED
NAME � CBL# •wuu wjl. ... • as r 1 iJ u�Olf1LLRY
( ` e Q `"-9 �ENGINE ING DUMP SITEDWLY
ADDRESS
5 r SEE DEMOLITION INSPECTION
FIRE RE WE ON l Li AC < oI JOB t w
CITY ZIP TELEPHONE i OR INSPECTION REQUIREMENTS x
L� VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY REQ'D COMPLETED EXEMPT
W� r �Z� (3 E3 YES i3 NO
PROPERTY TAX ACCOUNT PARCEL NO: CA# ZONE SIGN AREA HEIGHT
WAIVER 0',ALLOWED PROPOSED ALLOWED PROPOSED
STUDY D
❑ NEW RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
9ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
❑ ADDITION COMMERCIAL ❑ COMPLIANCE OR z
❑MIXED USE CHANGE OF USE z
❑ PARKING LOTAREA PLANNING REVIEWED BY DATE
❑REMODEL g
MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑❑GRADING ❑ FENCE X FT.) REMARKS
REPAIR CYDS
DEMOLISH ElTANK ❑ OTHER
❑ GARAGE RETAINING CARPORT ❑ ROCKERY WALL 1:1FIREA ARM FIRE LER
(TYPE OF USE, BUSINESS OR AC ITY) EXPAI
TYP CONSTRUCTION C E� OCCUPANT
CC ZWZu GROUPew
V)
NUMBER NUMBER OF
OF DWELLING J SPECIAL INSPECTION CONSULTANT OCCUPA
O STORIES UNITS / LOAD
"IREQUIRED DYES
DESCRIBE WORK TO BE DONE
I SIZ REMARKS z
�,c E
GEOTECH REPORT m
BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE --
Building Permit City Surcharge l
PLAN CHECK NO• Plumbing Base Fee
4S 5e
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO M@ChanIC81
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
t SEPARATE PERMISSION,
Engr. Review
W PERMIT APPLICATION: SEE ECDC 19,00.005(A)(5)
d PERMIT LIMIT: SEE ECDC 19.00,005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
*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
i 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 # f'
I HEREBY ACKNOWLEDGE THAT 1 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-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or acknowledged
edgediDeputy: and Fees are paid, and
IN VIOLATION O ABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S PEN TIO INSURANCE AND RCW 18:27, FF LS SIGN TURE DATE
SI AT ( WN O GEN) DATE 11N.ED (425) 771-0220 EL D ATE
ATf ENTION EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL -FILE • YELLOW -INSPECTOR
:ATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 I IRC110. PINK • OWNER • GOLD • ASSESSOR
PRESS HARD - YOU ARE MAKING 4 COPIES
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