20050478 (2).pdfFDATF RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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CITY ZIP TELEPHONE J (� 3
NAME
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PERMIT � /�N� _ � % /•
NUMBER
JOB SUITEIAPT#
ADDRESS 96
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A�PLAT NAMEISUBDIVISION NO. NO, LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved ❑
RW Permit Required ❑
Street Use Permit Required ❑
EXISTING PROPOSED Inspection Required ❑
Sidewalk Required ❑
REQUIRED DEDICATION _ FT __ Underground ❑
Wsiinq requited ❑
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRA.INAGE z
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ENGINEERING REVIEWED BY DATE
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STATS LICENSE NUMBER EXPI ATION DATE ED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
` /PI REQ�D COMPLETED EXEMPT
0 0 13YES 13NO
CA# ZONE SIGN AREA HEIGHT
PROPERTY TAXACCOUN PARCEL NO. 13
ALLOWED PROPOSED ALLOWED PROPOSED
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STUDY WAIVER
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NEW RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
COMMERCIAL COMPLIANCE OR
❑ ADDITION A00CHANGE OF USE
E]MIXED USE
PARKING LOT AREA PLANNING REVIEWED BY DATE
❑ REMODEL1:1 MULTIFAMILY ❑ SIGN REO'D . PROVIDED
❑GRADING ❑ FENCE
REPAIR
�CYDS X FT.) REMARKS
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gDWOCISH011tt ❑ I,J ❑ TANK ❑ OTHERGARAGE101t /C e� / It
RETANING'� ✓ /
❑ FIRE SPRI
CARPORT ❑ ROCKIERY WALL ❑ FIREALARM LER
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(TYPE OF USE, BUST S C IVITYk§&
� T E O Q(JRIJQTION Opti OCCUPANT
GROUP
NUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION r
NSULTANT OCCUPANT
STORIES UNITS LOAD
REQUIRED .E3 YES
DESCRIBE WORK TO BE DONE
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VALUATION
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Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LUT SLOPE% VESTED DATE
Building Permit � City Surcharge
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
J SEPARATE PERMISSION.
2 Engr. Review
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
IL PERMIT LIMIT: SEE ECDC 19,00.005(A)(0) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
y •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
w IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #'
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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 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• CALL Building Official or his/her Deputy: and Fees are 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
WORK S PENSATION SURA E AND RCW 18:27. UFFICI AlS SIrPNATAIRE DA E
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SIG U"01 A N DATE SIGNED (425)r/h
' 771w0220 RELEASED BY IJATF U
ATTENTION EXT. 1333 e
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. UBC1091 IBC110 I IRC1100 PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD YOU ARE MAKING 4 COPIES
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