20050234.pdfI
FOATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
780
NAME
ADDRESS
NAME
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CITY ZIP
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STATE LICENSE NUMBER
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1111--ol PROPERTY TAX ACCOUNT PARCEL NO.
NEW
AD131TION
REMODEL
REPAIR
DEMOLISH
GARAGE
CARPORT
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TELEPHONE
,42 d---7-1 300
EXPIRATIONDATE I CHECKED BY
19
RESIDENTIAL
El
COMMERCIAL
1:3
MIXED USE
11
MULTIFAMILY
11
GRADING
CYDS
TANK
E:iRETAINING
WALL
ROCKERY
ESS OR ACTIVITY) EXPL&N4
6ff�LUMBINq / MECH
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V.Q�e4CE OR
CHANGE OF USE
SIGN
FENCE
( _X FT.)
OTHER
FIRE SPRINKLER
FIREALARM
7 PERMIT
MIT
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I PERMIT EXPIRES
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ADDRESS
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PLAT NAME /SUrDIVI SION NO. LOT NO.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING _PROPOSED
REQUIRED DEDICATION ___ FT
METER SIZE LINE SIZE NO. OF FIXTURES
SUITE/APTf$
LID NO,
LID FEE S
TESCPApproyed
RW Permit Rerjuired
Street use Permit Required
Inspection Required
SKlowalk Requirea
Underground
Minn reawred
PRV REQUIRED
YESM NO 13
OBSERVED By CITY INSPECTOR
AFFIDAVITS SHALL NOT
BE ACCEPTED
ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE UJI
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VARIANCE OR CU SHORELINEORADB# I INSPECTION SEPA
REO'D 01COMPLETED I EXEMPT
13 YES 13 N
CAN ZONE SIGN AREA HEIGHT
WAIVER 13 ALLOWED I PROPOSED ALLOWED , PROPOSED
STUDY [3 1 1
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT URSIDE REAR
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PARKING LOTARE EVIEWED BY DATE
REO'D , PROVIDED I
REMARKS
OCCUPANT
GROUP
NUMBER
OF
STORIES
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1 NUMBER OF
DWELLING
UNITS
SPECIAL INSPE&TION
S P E C
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RE . QUIR . ED
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CONSULTANT
�C_Ck7PANT
LOAD
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DESCRIBE WORK TO BE DONE
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STRUCTURAJOESIGN
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VALUATION
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Description
FEE
Description
FEE
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11A
, Plan Check
State Surcharge
HEAT tod, cp�
LOT SLOP . E%
VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO:
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Plumbing
/'4
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
2 DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
It
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SEPARATE PERMISSION.
Engr. Review
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PERMIT APPLICATION: SEE ECDC 19.00,005(A)(5)
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
Lu IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
_1
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
0:
< ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
1:3 NY CITY ORDINANCE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF A
Landscapeinsp.
Total Amt. Due
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NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
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Recording Fee
Receipt# —1 Z)
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_
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
CALL
Building Official or hisitior Deputy: and Foes are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
receipt I cknowledged in space provided
FOR INSPECTION H -
WORKMEN'S COMPENS=URANCE AND RCW 18:27.
OF I GN'ITLktE I I DATE
(OWNER Od*"T): DATE SIGNED
(425)
4
LSIGNATURE
771-0220
R E L I]i(S t0y- 13) DAT E
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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