20050379.pdfEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
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CITY ZI TELEPHONE
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NUMBER
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ADDITION
REMODEL
REPAIR
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GARAGE
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(TYPE OF USE, E
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PERMIT �1.
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NUMBER
JOB
SUITE/APTif
ADDRERq A
PLAT NAME/SUBDIVISION NO. LOT N
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LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
I ESCP Approved
RW Pcrinit Required
13
E3
Str"t Use Po,mit Required
Required
11
13
EXISTING _ PROPOSED
inspection
13
sidewalk Requirw
13
REQUIRED DEDICATION FT
Undetgro, nd
Witing required
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METER SIZE
LINE SIZE
01 FIXTURES
PRV REQUIRED
YES 13 NOO
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION
CONTROUDRAINAGE
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ENGINEERING REVIEWED BY DATE
1� 62 bm n
FIRE REVIEWED BY DATE
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E XPIRATION DATE
I CHECKED BY
VARIANCE OR CU
SHORELINE OR ADB#
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INSREQTION
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I eYES 13NOI
SEPA
COMPLETED I EXEMPT
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CAH _05'- 2-+
WAIVER 12'
STUDY 13
ZONE
SIGN AREA
ALLOWED I PROPOSED
HEIGHT
ALLOWED PROPOSED
1
PARCEL NO.
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1:1 RESIDENTIAL
COMMERCIAL
1:1 MIXED USE
13 MULTIFAMILY
I GRADING
CYOS
PLUMBING I MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
( X FT.)
LOT COVERAGE
ALLOWED PROPOSED
I AI&
REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
FRONT SIDE REAR FRONT LIRSIDE REAR
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PARKING
REQ'D I PROVIDED
LOTAREA
PLANNING REVIEWED BY DATE a.
15 A /OT
REMARKS
TANK
OTHER
orETAINING WALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
i OR ACTIVITY) EXPLAIN.
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TYPI��ONSTRUVTION
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CE� I
OCCUPANT
GROUP
DESCRIBE WORK TO BE DONE
NUMBER OF
DWELLING
UNITS
SPE�IAC INSPECTION CONSULTANT OCCUPANT
REQUIRED 13YES I I LOAD I
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GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATI01"
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Description
Vim, ER�1'121
:1 ECULG-r
Plan Check
HEA S URCE LOTSLOPE%
2
VESTED DATE
Building Permit
PLAN CHECK NO:
—
Plumbing
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 (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE
Eng I r. Review
SEPARATE PERMISSION.
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
Engr. Inspection
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Fire Review
Fire Inspection
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Landscapelnsp.
and
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Recording Fee
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CALL
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FORINSPECTH
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IHEREBY CKNOW EDGE;Te / I HAVE READ THIS APPLICATION; THAT THE INFORMATION
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A �AND
GIVEN IS CORRECT, WI AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
AND 4
THE OWNER. I AGREE T C MPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING T ORK AUTHORIZED THETRA BY NO PERSON WILL BE EMPLOYED
1 0 T I
IN VIOLATION OF T ABOR CODE OF THE S E'OF WASHINGTON RELATING TO
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CW TION INS��NCE AND R 18:27.
WORKMEN'S C
(425)
SIGNATU R R NT)"
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DATE SIGNED
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71-0220
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FEE Description FEE
State Surcharge
City Surcharge
Base Fee
I I M UNAAA .70-S)
Plan Chk. Deposit
Receipt #
Total Amt. Due
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Receipt # �zu 9 z ) i.
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his her Deputy: and Fees are paid, and
receipt is "A"nowledged in space provided
MI A S SIGNA1 DATE
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SE BY DINTE
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IT IS UNLAWFUL TO UsE OR OCCUPY A BUILUING OR a I Kul,
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIG"---I11/LE YELLOW - INS ECTC
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 If IRC110. PINK - OW14ER GOLD ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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FINAL PROJECT APPROVAL FORM
FINAL PROJECT APPROVAL FORM