20050159.pdfI
DATE RECEIVED
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PERMIT EXPIRES
CITY OF EDMONDS
PERMIT
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CONSTRUCTION PERMIT APPLICATION
JOB SUITE/APT#
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ADDRESS -vil -
OWPER NAME
/N AME OF BUSINES
PLAT NAME/SUBDiVISION NO.
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LOT NO.
LID NO.
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MAILINGADDRESS
LID FEE S
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApproved E3
RW Prinnit Required 13
EXISTING PROPOSED
Street Use Pern1d Required 13
Inspeclion Required [3
CITY zip
TELEPHONE
REQUIRED DEDICATION FT
Siduoalk Required 0
Underground Cl
Wiring toguifed 0
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YESE3 NOC3
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ADDRESS
REMARKS
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OWNER]CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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ENGINEERING REVIEWED BY DATE
ADDRESS
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FIRE REVIEWED BY DATE
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CITY ZIP
TELEPHONE
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VARIANCE OR CU
SHORELINE RADB#
INSPECTION
REO'D
SEPA
STATE LICENSE NUMBER EXPIRATION DATE
CHECKED BY
COMPLETED EXEP.IPT
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WAIVER 13
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SIGN AREA
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STUDY E3
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E3 NEW �(RESIDENTIAL PLUMBING ir MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
. FRONT L/R SIDE REAR
COMMERCIAL COMPLIANCE OR
El ADDITION
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MIXED USE CHANGE OF USE
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REMODEL ED SIGN
MULTIFAMILY
REQ'D PARKING
PROVIDED
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PLANNING REVIEWED By DATE I ,
GRADING FENCE
REPAIR CYDS ( X FT.)
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1:1 DEMOLISH E:] TANK DAr
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GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT
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ROCKERY FIREALARM
(TYPE OF USE, BUSINESS ORACTI11Y) EXPLAIN:
TYPE OF CONSTRUCTI
OCCUPANT
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NUMBER
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CONSULTANT
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STORIES
UNITS
REQUIRED 13YES
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
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GEOTECH REPORT
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BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
LOT SLOP�7_�
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
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a.
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
(n 'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
Ui
_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 # Oz_�o I
x 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 2q) 0�-
0 NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
Recording Fee �71 0 Receipthl ft% Ll tp
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT, AND T14AT 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
receipt is acknowledged in space provided.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S C0/01I!7!�SATION INSURANCE AND RCW 18:27. 1
FI�C,I�LS SIGNATU E DATE
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� )R T): DATE SIGNED (425) ( 11, 1/. If , ,
G N AT U R E R AGEN
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771-0220 RaLVASED B DA*,
ATTENTION EXT. 1333
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IT IS UNLAWFUL 1*0 USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL L , I
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- �INAL - FILE��YELLOW - INSPEC6
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / iBC1110 i !RiCiiO. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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