20050457.pdfE
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
5e(G 4A"ase. / ,r co2r/
MAILING ADDRESS
CITY ZIP TELEPHONE
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NAME
ADDRESS
112017 I I PERMIT EXPIRES f 11
PERMIT
NUMBER
JOB SUI E APT#
ADDRESS
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO. /
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved O
RW Permit Required
Street Use Permit Required
EXISTING PROPOSED Inspection Required O
Sidewalk Required 13
REQUIRED DEDICATION FT Underground O
Witing required E3
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NOE3 z
IY
w
REMARKS w
OWNER/CONTRAC*JESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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NAME I CBL# TANK FILL. . REMOVAL. P
d A1I# C / ENGINEERING REVIEWED BY DATE
ADDRESS
Awl� FIRE REVIEWED BY DATE w
CITY ZIP TELEPHONES
STATE LICENSE NUMBER EXP TION ATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
2 L_r REQ'D COM LET D EXEMPT
rES�D i�7t %94& YES NO
CA# — ZONE SIGN AREAIGHT
PROPERTY TAX ACCOUNT PARCEL. NO.
WAIVER �. 1 ALLOWED PROPOSED ALLOWED .PROPOSED
DD0
O STUD O ~'
❑ NEW ❑ RESIDENT IAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT. UR SIDE REAR t7
COMMERCIAL COMPLIANCE OR—�
❑ ADDITION ❑ CHANGE OF USE z
❑ MIXED USE PARKING LOTAREA PANNING REVIEWED BY DATE �( g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑ ❑ .GRADING El
FENCE a no
REPAIR CYDS X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
❑GARAGE RETAININIRE
CARPORT ❑ ROCKE YG WALL ❑ FIREA ARM SPRINKLER
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
cNUMBER NUMBER OF
OF DWELLING SPECVL INSPECTION CONSULTANT OCCUPA T
p STORIES / - UNITS LOAD
REQUIRED OYES
DES I5,kVORK TO BE DONE
REMARKS 0
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�L S'�4� GEOTECH REPORT In
f_ BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description FEE Description FEE
Plan Check 4�,;7: State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee
i
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO McChanICBI
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
t SEPARATE PERMISSION,
Engr. Review
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
N *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
:E EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection /% �� Receipt #
Q 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
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' ,
Recording Fee 1 Receipt # r
I HEREBY ACKNOWLEDGE THAT 1 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• CALL Building Official or his/her Deputy: and Foes aro paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged in space provided.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION f[{$URANCE AND RCW 16:27, O IALS SIGNA URE DATE
SIGNATURE (OWNER 071ATEIZI DATESIGNED p� (425)
771 -0220 REL ASE BY j6ATE
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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