20050301 (2).pdfC +✓ DATEFRECEIVED )
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
w MAILING ADDRESS
CITY ZIP TELEPHONE
NAME
NAME �.�- `'i( ,tom CO /V S r � l tlLr7I
ADDRESS
CITY ZIP TELEPHONE
STATE LICENSE NUMBER EXPIRATION/DATE Ckf CKED BY
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PROPERTY TAX ACCOUNT PARCEL NO. !f 3 (l fvw & oo 10,9 v 3
00 y y e -amt eva I -v 0
❑ NEW 11RESIDENTIAL 1:1PLUMBING I MECH
COMMERCIAL COMPLIANCE OR
❑ ADDITION ❑ CHANGE OF USE
MIXED USE
❑ REMODEL ❑ MULTIFAMILY SIGN
GRADING FENCE
❑ REPAIR ❑ CYDS ❑ ( X FT.)
❑ DEMOLISH ❑ TANK ❑ OTHER
GARAGE RETAINING ❑ WALL FIRE CARPORT ❑ ROCKERY ❑ FIREALLER
ARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER NUMBER OF
[ERMIT EXPIRES /Z?a
PERMIT r:��L%
NUMBER
ADDRESS r JOB
SUITE/APT#
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET, MAP TESCPApproved O
RW Permit Required Cl
Street Use Permit Required 0
EXISTING/ PROPOSED Inspection Required
Sidewalk Required
REQUIRED DEDICATION FT underground E3
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Wirino required
METER SIZE LINE SIZE
NO. OF FIXTURES PRV REQUIRED
/
YES[3 NO [3 3
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE z
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ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE W
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REO'D COMPLETED I EXEMPT
M e**' ES 0 NO ✓
CA# ZONE S!GN AREA HEIGHT
WAIVER O - ALLOWED PROPOSED ALLOWED PROPOSED
STUDY 4 2. Lp IAI Tr
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LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIR SIDE REAR t7
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PARKING LOTAREA PLANNING REVIEWED BY DATE n
REQ'D PROVIDED
TYPE55ONST(2UCrION I Cj,Q0�2 I GROUP NT
0 OF, / DWELLING /� - SPEC IAL INSPECTION CONSULTANT OCCUPANV
M STORIES UNITS . (C & ( 4 (%L LOAD
DESCRIBE WORK TO BE DONE REQUIRED YES
AMA C 14- 7`c k ( H S&Aoe REMARKS O
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TU GEOTECH REPORT
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BY: / Y
,/ STRUCTURAL DESIGNopt
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BY:
VALUATION
$
Description FEE Description FEE
Plan ChecState Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit , J�� � City Surcharge. I
PLAN CHECK NO: �.. Plumbing Base Fee
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)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
U 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 LandSCape InSp. fOlal Amt. Due
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' r
Recording Fee Receipt # i{(
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/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
x WORKMEN'S COMPENSATION INSURANCE AND RCW 10:27. C
%LS SIGN TURE DATE
11 \ SIGNA NER OR GENT). DATE SI ED C42 J,n
G S0 771-0220 RE A D BY ATE
ATT NTION EXT. 133300
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL L2 ' r
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL .FILE YELLOW -I SPECT R
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109J IBC110I IRC110. PINK -OWNER • GOLD ASSESSO
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
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