20050114.pdfDATE RECEIVED
07Y 144 L L /4�_6 Y
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
PERMIT EXPIRES
PERMIT
NUMBER
JOB
ADDRESS
SUITEIAPT#
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PLAT NAME/SUBDIVISION NO.
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LID NO.
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LID FEE S
MAILING ADDR&J
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved [3
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RW Permit Required
EXISTING PROPOSED.
Street use Permit Required
Inspection Requited 13
CITY ZIP
TELEPHONE
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REQUIRED DEDICATION FT
Sidewalk Required E3
Underground 13
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NAME
METER SIZE
LINE SIZE
NO, OF FIXTURES
PRV REQUIRED
ADDRESS
NAME
ADDRESS
CITY
NEW
ADDITION
REMODEL
REPAIR
DEMOLISH
GARAGE
CARPORT
(TYPE OF USE. B
ZIP I TELEPHONE
EXPIRATION DATE I CHECKED BY
RESIDENTIAL
COMMERCIAL
MIXED USE
MULTIFAMILY
GRADING CYDS
TANK
RETAINING WALL
ROCKERY
OR ACTIVITY) EXPLAIN
1:1 PLUMBING / MECH
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COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
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OTHER
FIRE SPRINKLER
FIREALARM '
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY DATE
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VARIANCE OR CU SHORELINE RADB# I INSPECT SEPA
REO'D COMPLETED EXEMPT
OYES 113ON01 I
CA# ZONE SIGN AREA HEIGHT
WAIVER E3 ALLOWED I PROPOSLEDALIOWED , PROPOSED
STUDY 13 1
LOT COVERAGE REQUIRED SETBACKS FT PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIR SIDE REAR
PARKING LOTAREA PLANNING REVIEWED BY DATE
REO 'D PROVIDED
FT.)
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TYPE OF CONSTRUCTION,
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JOCCUPANT
GROUP
NUMBER
OF
STORIES
NUMBER OF
DWELLING
UNITS
SPECIAL IN�PECTION
REQUIR ED
CONSULTANT
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
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GEOTECH REPORT
BY:
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STRUCTURAL DESIGN
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VALuATibN
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEATSOURCE
& C_
LOTSLOPE%
VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Grading
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT. SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
In 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
in
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_j IN INTEREST, AGREES TO.INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 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 Landscapelnsp. Total Amt. Due
21 NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
— Recording Fee Receipt #
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/tier Deputy: and Foos are paid. and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED receipt is acknowledged in space provided.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
OFFICIALS SIGNATURE QATE
S 0 DATE SIGNED (425) i(
t7� , n - C:, I
1_� I . -Z- 771-0220 REISED BY DATE
ATT T�& EXT. 1333 e
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IT IS UNLAW UL To USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 2129MOU2
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL - FILE YELLOW
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC110 / IRC110. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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