20050470.pdfDATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/14AME OF BUSINESS
MAILING ADDRESS
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PERMIT EXPIRES 2
PERMIT
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LAT NAME /SUBDIVISION NO. LOT NO. LID NO
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PU13LIC RIGHT OF WAY PER OFFICIAL STREET MAP pritroved
RW Permit Rriquired
Street Use Permit Requited
EXISTING PROPOSED inspecwn Required
Sidewalk Required
REQUIRED DEDICATION FT Underground
Witing required
METIR SIZE LI�E SIZE 0,9F FIXTUffs PRVREQUIRED
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OWNE�/CONWXCTOR RESPONS113LE FOR EROSION CONTROUDRAINAGE
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PIRURVED BY CITY INSPECTOR
qa I ENGINEEirltTG' RNONVITS SHALL NOT DATE
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STATE LICENSE NUMBLR EXPIRATION DATE
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WAIVER A' ALLOWED
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MIXED USE PARKING LOTAREA PLANNING REVIEWED BY DATE
REMODEL MULTIFAMILY SIGN REQ*D ROVIDED
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REPAIR GRADING CYDS ( — X — FT.) REMARKS VE (PRV
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GARAGE RETAINING WALL FIRE SPRINKLER
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(TYPE OF USE, BUSINESS OR ACTIVII Y)i TYPE Orr OC UPAN
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71 F 5E�E WORK TO BE DONE REMARFIKS
GEOTECH REPORT
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Description"""""
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Pl,an Check
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VESTED DATE
Building Permit
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PLAWCHECK NO:
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Grading
Engr. Review
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 SUCCFSSORS
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.0
Fire Review
Fire Inspection
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Recording Fee
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABO CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S COMPENSAT)OTININ[W RANCE AND RCW 18:27. 1
SIGNA,*RE (OWNER 0 NT): DfE St NED (425)
EXEMPT
PROPOSED
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FEE
Description
FEE
State Surcharge
City Surcharge
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Base Fee
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Plan Chk. Deposit
Receipt #
Total Amt. Due
It Receipt #
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 acknowledgXd in space provided
,;7) �u, -ItA, 140 �6 771-0220 1 IX
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AYTItNTION f f � 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-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 I IRC110.
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECI OR
PINK - OWNER GOLD - ASSESSOR
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