20050376.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
CITY 'ZIP TELEPHONE
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NAME
ADDRESS
TELEPHONE
f PERMIT EXPIRES %fy
PERMIT
NUMBER 71;' C/ir
JOB SUITE/APTk
ADDRESS
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PLAT NAMEISUBDIVISION NO. LOT NO. LID NO,
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved tJ
RW Permit Required El
Street Use Permit Required I'
EXISTING _ PROPOSED _ Inspection Required O
Sidewalk Required 13
REQUIRED DEDICATION FT Underground O
Wain required Q
METER SIZE LINE SIZ7 NO. OF FIXTURES PRV REQUIRED
YES 13. NO O z
REMARKS WW
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE z
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NAME I C`B-L#
UGS or e. e 62 S 7 ENGINEERING REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATION DATE CKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REO'D COIdPLETED I EXEMPT
CJ.s OYES ONO
CA# ZONE SIGN AREA HEIGHT
Q PROPERTY TAX ACCOUNT PARCEL NO.
�+, WAIVER O ALLOWED PROPOSED' ALLOWED PROPOSED
� (/ D S`/ n �'OcuO U% STUDY O
RESIDENTIAL LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
NEW PLUMBING / MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT LJR SIDE REAR
❑ COMMERCIAL COMPLIANCE OR _
❑ ADDITION ❑ CHANGE OF USE z
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REDID PROVIDED
❑ REPAIR ❑ GRADING CYDS ❑ FENCE X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
z ❑GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ❑ ROCKERY ❑ FIREALARM
a(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
F, TYP N T UCTION OCCUPANT
GROUP
Lu NUMBER NUMBER OF
OF DWELLING SPECIAL INSPEC I N CONSULTANT OCCUPANT
p STORIES UNITS LOAD
REQUIRED DYES
DESCRIBE WORK TO BEDONE
I REMARKS _
^ C % GEOTECH REPORT
BY:
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I BY:
j jaiJS l r,c.fil VALUATION
$
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOTSLOPE% VESTED DATE �—
Building Permit City Surcharge r
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical
fBE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Grading
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
t SEPARATE PERMISSION.
wPERMIT APPLICATION: SEE ECDC 19.00,005(A)(5) Engf. R@VIEW
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. 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
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fife Inspection Receipt #
a 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
0 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 Fees aro 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 COMPENSATIOro NCE AND RCW 18:27. ffI L SI TURE DATE
SIGNATURE (OWNER OR GENT): DATE SIGNED (425)
'C 771=022Q REL SED BY D E
1—
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 / IRC110. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD =YOU ARE. MAKING 4 COPIES
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