20050431.pdfCEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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rAAILIN�ADDRESS
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NAME
ADDRESS
NAME
ADDRESS
CITY
TELEPHONE
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PERMIT EXPIRES
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PERMIT
NUMBER
JOB SUITE PTss
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PLAT NAMEISUBDIVISION NO.
LOT NO.
LID NO�
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LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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0
0
�XISTING PROPOSED
RW Permit Required
Street Use Permit Required
Inspection Required
13
E3
Sidewalk Required
[3
REQUIRED DEDICATION
FT
Underground
E3
13
Wirino tonuired
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YESO NOM
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ENGINEERING REVIEWED BY
DATE
FIRE REVIEWED BY DATE
PURSUANT TO UPC 605.2
STATE LICENSE NUMBER
EXPIRATION DATE
CHECKED By
VARIANCE OR
S
HE INS
OMPLETED EXEMPT
CA#
SIG
AT
HEIGHT
PROPERTY TAX AC COUNT PARCEL U&;-.
WAIVER [3
ALLOWE PROPOSED
ALLOWE PROPOSED
STUDY [3
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NEI N
RESIDENTIAL
rLU1MB1,NG ECH
LOT COVERAGE
REQUIRED SETBACKS (FT)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT URSIDE REAR
ADDITION
COMMERCIAL
MPLIANCE OR
MPL
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MIXED USE
CHANGE OF USE
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PARKIN
LOT AREA
PLANNING REVIEWED BY DATE 5
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1:1 MULTIFAMILY
SIGN
REQ'D
PROLDED
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REPAIR
GRADING
0 CYD-S
FENCE
1:1 ( X FT.)
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REMARKS
DEMOLISH
13 TANK
OTHER
1:1
EiGARAGE
E] RETAINING WALL
FIRE SPRINKLER
0
CARPORT
ROCKERY
FIREALARM
(TYPE OF USE, BUSINESS OR ACT,,IVITY�, EXPLAIN:
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OCCUPANT
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NUMBER OF
OF
DWELLING
SPECIAL INSPECTION
CONSULTANT
OCCUPANT
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LOAD
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DESCRIBE WORK TO BE DONE
REMARKS
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GEOTECH REPORT
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STRUCTURAL DESIGN
BY:
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
LOT SLOPE7_._-7—VESTEDDATE
Building Permit
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 (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engn Review
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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
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
to
Fire Review
Plan Chk. Deposit
UJI IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
2 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
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1
I Total Amt. Due
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0 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 Official or hisihor Deputy: 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.
WORKM§N'S SATION INSURANCE AND RCW 18:27.
OFFICIZ� DATE
S71G7ATkl(0 W E Rb R A G E N T): DATE SIGNED
(425)
\IGNATUREa
11_1� Ii, C-)17(- _166
771-0220
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'RELEASED
BY DATE'
TTE
A TTE
EXT. 13313
U
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IT ISk"L F L TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FI SPECTION 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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