20050266.pdfI
DATE. RECEIVED
[PERMIT EXPIRES
PERMIT
6CITY OF EDMONDS NUMBER -oauo
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
OWNER NAME/NAME OF BUSINESS ADDRESS f, /�/)i1 �i L/
LE C O PLAT NAMEIS`xUBD`IVIS`ION NO. LOT NO. LID NO
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street Use Permit RW Permit lRequited Ell f
CITY ZIP ^^y�/�� TELEPHONE EXISTING PROPOSED Inspection Required E3
O D G" ` _ — UnSidewalkrRequited 0
REQUIRED DEDICATION FT Underground O
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NAME METER SIZE LINE S1ZE NO. OF FIXTURES PRV REQUIRED
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ADDRESS REMARKS w
UOWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE C ECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
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❑ NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) M
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR C
13COMMERCIAL COMPLIANCE OR �� ? m
❑ ADDITION ❑ MIXED USE ❑ CHANGE OF USE z n
PARKING LOT AREA P NNING REVIEWED BY DA E 5 1 O C
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MULTIFAMILY ❑ SIGN REO'D PROVI D
FENCE T� Ll.'�' 5 1476= M
❑ REPAIR ❑3RADING CYDS ❑ ( X FT.) REMARKS p Z
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❑ DEMOLISH ❑ TANK ❑ Z
GARAGE _ ❑ CARPORT ❑ ROCKERY RETAINING WALL ❑ FIREA ARM FIRE LER
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(TYPE OF USE, BUSIN S OR ACTIVITY) EXPLAIN:
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m OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT m m
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DESCRIBE WORK TO BE DONE 0
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Building Permit City Surcharge . 11
PLAN CHECK NO:n
Plumbing Base Fee < <! J
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION,
Engr. Review
w 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
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
ui IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M 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 /, �'J C
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee I Receipt # C
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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application Is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Depuly: and Fees aro paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S CO NSATION INSURANCE AND RCW 18:27.
OFC N •DATE
SIGNATU OWN R Me E TV, DATE SIGNED (425) �� �`•�
1 n _
` ✓ V I _ `� 771'0220 REL A ED BY DAVE
ATTENTION EXT. 1333 I,�
ITIS 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. UBC1091 IBC1101 IRC110. PINK -OWNER • GOLD - ASSESSOR
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