20050332.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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NAME
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PERMIT EXPIRES
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PERMIT
NUMBER 2005 - C53oz-
JOB SUITEIAPT#
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PLAT NAMEtSUBDIVISION NO.
NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApproved
RW Permit Required C3
EXISTING PROPOSED
Street Use Permit Required
Inspection Required
Sidewalk Requited E3
E3
REQUIRED DEDICATION FT
Undrutpound
Wilma required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES13 NOO
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REMARKS
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLdDRAINAGE
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ENGINEERING REVIEWE
FIRE REVIEWED BY
DATE
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STATE LICENSE NUMBER
EXPIR T N DATE
VARIANCE OR CU
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INSPECTION
SEPA
COMPLETED EXEMPT
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SIGN AREA
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PROPERTY TAX ACCOUNT PARCEL NO.
30
WAIVER 13
13
ALLOWED PRO SED
ALLOWED PROPOSED
STUDY
0 NEW
RESIDENTIAL
PLUMBING MECH
LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT
L/RSIDE REAR
1:1 ADDITION
rMIXED
COMPLIANCE OR
CHANGE OF USE
1:1 REMODEL
USE
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PROVIDED
LOTAREA
REVIEWED BY
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SIGN
REQ'D
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11 REPAIR
GRADING
CYDS
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REMARKS
1:1 DEMOLISH
TANK
0
IGARAGE
RETAINING WALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIREALARM
(TYP�AFUSE,BUSINESVMACT TY)EXPL IN:
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TYPE OF CONSTR C [ON CCQE OCCUPANT
i 7 i GROUP
u NUMBER NUMBER OF
OF DWELLING SPECIAL ll�ISPECTION CONSULTANT OCCUPANT
a II, I UNITS 3 LOAD
:) STORIES
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DESCRIBE WORK TO BE DONE
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36 11 "D6.5CtAV-f__,3Ae\ Description FEE Description FEE
10 "61 VV`IrJ1\Ay\ bWkA(!2�� Plan Check State Surcharge
HEAT SOURCE LOTSLOPE% _,��STED DATE Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee Af5
Mechanical.
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 Grading
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SEPARATE PERMISSION.
Engr. Review
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
to
IM
_j 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 A . NY CITY ORDINANCE Landscapelnsp. *Total Amt. Due
1
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
x I Recording Fee —[Receipt #
_-MI
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 COMPLYWITH 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
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. OFFjG+ALS SJGNATPRE
NATURE (OWNER ORtIGENT) DATE SIG ED (425) qb
2tW
A V_C
0220
771- 7FEASED 13Y GATJ
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 If IRC110. PINK -OWNER GOLD - ASSESSOR
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
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