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r PERMIT EXPIRES
MIT
CITY OF EDMONDS Nu BER
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
ADDRESS % -7 �
OWNER NAME/NAME OF BUSINESS ( `� X1'2Q'✓ 4Z- ,CA w/e�
PLAT NAME ISUBDIVISION NO. LOT NO. LID NO,
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MAILING ADDRESS LID FEE 5
96 2? �,� QA �,� PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Pe mil Required
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Street Use Permd Required ❑
CITY ZIP TELEPHONE f EXISTING_ PROPOSED nsvereun Roqueen ❑
Z(36 l SW13owilh Required
CVWO �lJS s 76 —�� s REQUIRED DEDICATION _ _ FT Wi ingrreuwred ❑
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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I— ADDRESS REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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NAME �% n CBL# �J
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"1 PROPERTY TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA I HEIGHT
L7 WAIVER 13 ALLOWED PROPOSED ALLOWED PROPOSED
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❑ NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
ICOMMERCIAL COMPLIANCE OR z
❑ ADDITION MIXED USE ❑ CHANGE OF USE z
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❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑ ❑ GRADING ❑ FENCE
REPAIR CYDS X FT.) REMARKS
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DEMOLISH ❑ TANK O E
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(TYPE OF USE, MINESS OR ACTIVITY) EXPLAIN:
TYPJE OF CONSTRUCTIONCOD OCCUPANT
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La NUMBER OF
OF DWELLING SPECIAL I PECT10CONSULTANT OCCUPANT .
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Description FEE Description FEE
Plan Check v — State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE e --
Building Permit City Surcharge /
PLAN CHECK NO; Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WOR9 NOTED. THIS PERMIT COVERS WORK TO MBChanICBI
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
f DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
t SEPARATE PERMISSION,
Engr. Review
W PERMIT APPLICATION: SEE ECDC 19,00.005(A)(5)
4 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 RBVIBW Plan Chk, Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
:E EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
s 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
2 NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION,# _
Recording Fee Receipt #
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 his/her Deputy: and Foes are 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 COMPENSATION INSURANCE AND RCW 18:27.
OF 1 ALS SIGN TURE - DATE
SIG NATU E (OWNER OR GENT DATE SIGN�E•D (425)
4A 2
771-0220 �RELEASED BY DAT
AT NTION ' EXT. 1333
IT I 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 I IRC110• PINK -OWNER GOLD - ASSESSOR
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
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