20050357 (2).pdfDATE RECEIVED 1`
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED
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d PROPERTY TAX ACCOUNT P R EL
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❑ NEW RESIDENTIAL ❑ PLUMBING / MECH
❑ COMMERCIAL. COMPLIANCE OR
❑ ADDITION ❑ CHANGE OF USE
❑ MIXED USE
XL� REMODEL ❑ MULTIFAMILY ❑ SIGN
❑
GRADING FENCE REPAIR ❑ CYDS ❑ ( X
❑ DEMOLISH ❑ TANKGARAGE ❑ OTHER
❑ CARPORT ❑ ROCKERY RETAINING WALL FIRE ❑ FIREALARM LER
(TYPE OF USE, BUSINESS OR ACTI ITY) AIN
PERMIT EXPIRES
PERMIT A -
NUMBER
JOBSUITEIAPTn
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PLAT NAMEiSUBDIVISION NO /-f LOT NO LID NO
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved O
RW Permit Reguucd 17
Street Use Pormil ReUuval 13
EXISTING PROPOSED Inspection Reguvud 13
Sidewalk Rogwrud 0
REQUIRED DEDICATION FTUnderground D
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METER SIZE LINE SIZE NO OF FIXTURES PRV REOUMED
YES D NOD z
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE z
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ENGINEERING REVIEWED
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BY
DATE
FIRE REVIEWED BY
DATE
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VARIANCE OR CU
SHORELINE OR ADB#
INSPECTION
SEPA
BY
REQ'D
COMPLETED EXEMPT
D YES Cl NO
CAH
ZONE
SIGN AREA
HEIGHT
WAIVER D
ALLOWED PROPOSED,
ALLOWED PROPOSED
STUDY D
LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LIR SIDE REAR
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PARKING
LOT AREA
PLANNING REVIEWED BY DATE
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REO'D PROVIDED
REMARKS
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j TYPE OFC RUCTION COD OCCUPANT
i GROUP
NUMBER ' NUMBER OF
l OF I -�'' DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES ', UNITS LOAD
1 REQUIRED 13YES
DESCRIBE WORK TO E DONE
REMARKS i
AT L2A Irl 1n 11 ma, .1 GEOTECH REPORT m
} BY:
TV STRUCTURAL DESIGN
BY:
VALUATION
$ 12��
Description FEE Description FEE
Plan Check l State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit l City Surcharge %
PLAN CHECK NO: Plumbing Base Fee
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS,. DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
J SEPARATE PERMISSION.
Engr. Review
u PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
> PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Inspection
n •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
y 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 # IL
a 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
M DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape lnsp. Total Amt. Due VG/
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.• r
Recording Fee Receipt # y
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPR VAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF This application is not a pornllt 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
IN VIOLATION. OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged In space provided.
WORKMEN'S C ATION INSURANCE AND RCW 18:27. OFFI LS SIGNAT E I DATE
SIGNATURE ( WNER AG T): DATE SIGNED (425) 1 ` �I
.�O/ `' - 771-0220 R / D BY - DATE
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 - INS CTO
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 I IBC110 if IRC110. PINK • OWNER • GOLD - ASSESSO
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