20050402.pdfI L
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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NUMBER
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PLAT NAMEISUBDIVISION NO. LOT NO. LID NO,
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved ❑
RW Permit Requited ❑
Street Use Permit Regwrert ❑
EXISTING PROPOSED Inspection Requited O
Sidewalk Requited ❑
REQUIRED DEDICATION FT Underground ❑
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Wiring required ❑
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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FIRE REVIEWED BY DATE
CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE CH Y VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
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REO'D COMPLETED EXEAIPT
F/l.�(/ i �U O %� � Q l e '/ ,r i3 NO
CA# ZONE SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO.
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DEMOLISH
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XIXI RESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
11 ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ COMMERCIAL COMPLIANCE OR
❑ MIXED USE CHANGE OF USE
PARKING LOTAREA PLANNING REVIEWED BY DATE
❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑
GRADING FENCE
CYDS ❑ ( X FT.) REMARKS
TANK ❑ OTHER
RETAININol ❑ CARPORT ❑ ROCKERY G WALL ❑ FIREAL FIRE RM LER
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(TYPE OF US€, BUSINESS ORA TIVITY LAIN: ,
I I me Coln m� S I GvV'E� TYPE OF CO C I D OGFTQ
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i NUMBER NUMBER OF
OF DWELLING J SPECIAL INSPECTION CONSULTANT OCCUPANT
j STORIES UNITS ( - LOAD -
s REQUIRED YES
DESCRIBE WORK TO BE DONE
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/'I D,V D C.. (/1 /� �/�� GEOTECH REPORT
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VALUATION
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Q U�Nfi l d le � �� � Description FEE Description FEE
4?HW f f .010;l Plan Check State Surcharge
HEAT "CELOT SLOPE% VESTED DATE
Building Permit oirCity Surcharge /S '
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
SEPARATE PERMISSION. Engr, Review
CC PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
IL PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
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 t
_ FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE r
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due
O NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
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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 receipt pt is acknowledged in space provided.
or his/her Deputy: and Faits are paid, and
IN VIOLATION OF. THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION rece
WORKMEN'S COMAENSATION INSURANCE AND RCW 18:27,
OF Cl S $SNA E ATE
SIGNATJU ER OR GENT): DATE S / NED 1 (425) / ,LL
L/ 771'0220 RELE EDB 111111111111 IDATE
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 I IBC110 I IRC110. PINK -.OWNER •GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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