20050145A.pdfI
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CITY OF EDMONDS t
CONSTRUCTION. PERMIT APPLICATION J(
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PROPERTY TAX ACCOUNT PARCEL NO.
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MIXED USE CHANGE OF USE
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REPAIR CYOS ( X FT.)
DEMOLISH TANK OTHER
GARAGE RETAINING WALL FIRE SPRINKLER
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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 PERMIS;ION.
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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
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NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT: AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
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
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S INSURANCE AND RCW 18:27.
,C^E,NSATION
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DATE SIGNED
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LAT NAME/SUBDIVI SION NO,
LOT NO
LID NO,
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LID FEE S
uaLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Required
Street Use Permit Requited
XISTING — PROPOSED
Inspection Required
SAo*alk Required
EQUIRED DEDICATION
FT
Undorground
Wirinq ionuired
METER SIZE
LINE SIZE
NO� OF FIXTURES
PRV REQUIRED
YES13 NOO
!EMARKS
)WNERICONTRACTOR RESPONS113LE
FOR EROSION, CONTROLIDRAINAGE
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REQ'D COMPLETED I EXEMPT
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CAN Z014E SIGN AREA HEIGHT
WAIVER13 ALLOWED , PROPOSED ALLOWED , PROPOSED
STUDY 13 1 1
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT URSIDE REAR
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REMARKS
TYPE
SPECIAL INSPECTION
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REMARKS /I
GEOTECH REPORT.
BY:
STRU CTURAL DESI�
BY:
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recordina Fee
CALL
FOR INSPECTION
(425)
771-0220
OCCUPANT
GROUP
OCCUPANT
LOAD
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FEE Description
State Surcharge
City Su rcharge
Base Fee
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt # r
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receiril,is acknowledged in space provided.
OfEj�JAL I i RE DATE
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RELEASED BY k—/ DAIE
=YT 1 1
T-I&1UGN;lq1rW1Fr1UL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL _fNSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC110 / IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL -FILE YELLOW -INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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