20050368.pdfDATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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NAME
ADDRESS
LEPHONE
PERMIT EXPIRES
'PERMIT
NUMBER
JOB SUITEIAPTH
ADORE C—_—,
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PLAT NAME-iSUBDIVISION NO
LOT NO
LID NO
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
13
RW Pemlit Required
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Street Use Permit Required
13
EXISTING PROPOSED
Inspection Required
13
Sidowalk Required
13
REQUIRED DEDICATION FT
Uncietiground
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13
Waing required
METER SIZE
LINE SIZE
07 FIXTURES
PRV REQUIRED
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YESO NOO
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REMARKS
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OWNERiCONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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NAME
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ENGINEERING REVIEWED
BY DATE
ADDRESS
FIRE REVIEWED BY
DATE
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CITY
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VARIANCE OR CU
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INSPECTION
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SEPA
COHPLETED I EXEMPT
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STATE LICENSE NUMBER EXPIRATION DATE
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CHECKED BY
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WAIVER
STUDY
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SIGN AREA
ALLOWED PROPOSED
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ALLOWED ROPOSED
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PROPERTY TAX ACCOUNT PARCEL NO.
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NEW
E ADDITION
REMODEL
RESIDENTIAL
E] COMMERCIAL
E] MIXED USE
MULTIFAMILY
1:1 PLUMBING MECH
COMPLIANCE OR
17 CHANGE OF USE
11 SIGN
LOT COVERAGE
ALLOWED PROPOSED
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REQUIRED SETBACKS (FT)
FRONT SIDE REAR
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PROPOSED SETBACKS
FRONT LIRSIDE REAR
4-1-
PARKING
REQ'D PRC VIDED
(JLOT AREA
EVIEWED BY DATE
0 R . EPAIR
GRADING
CYDS
FENCE
X FT.)
REMARKS
DEMOLISH
TANK
OTTER
�- e;
GARAGE
CARPORT-
RETAINING WALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS
OR AC ITY) Xp
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COM
OCCUPANT
GROUP
NUMBER
OF
STORIES �,�
75
NUMBER OF
DWELLING
UNITS
SPE&AL INS'PECTICTN
REQUIRED
CONSULTANT
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE I
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GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
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Des'Cription
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
7
City Surcharge
PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN DRIVEWAYS,
(CURBS, SIDEWALKS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
Engr. Inspection
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHA . LF 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
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
Landscapeinsp.
Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee
Receipt 0
1 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 porrim 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 hisitter Dopuly and Fees 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 COMPEN SATIO!,AQU RANCE AND RCW 18:27.
OFFICIALS SIGNATURE DATE
SIGNATURE (OWNER OR, ENT)1: DATESIGNED
(425)
A
771-0220
RELEASED BY AT E
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-
P CT
YELLOW -INS CTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110.
PINK -OWNER GOLD - ASSESSOR
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
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