20050479.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
O"ER NAME/NAME 9f BUSINESS
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MAILING ADDRESS 1
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NUMBER 1-Cj(1 -Ci L1 l C1
JOB SUITE/APTa
ADDRESS 5 n
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved O
RW Permit Required 0
Street Use Permit Required 13
EXISTING PROPOSED __• _ Inspection Requires E3
Sidewalk Required O
REQUIRED DEDICATION FT Underground O
-- — Wem required E3
METER SIZE LINE SIZE NO, OF FIXTURES PRV REQUIRED
YES D NOD Z
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REMARKS w
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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(J ENGINEERING REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADBa INSPECTION SEPA
COri ' yw1Ir 61 REDID COMPLETED EXEMPTD YES D NO
CAa ZONE SIGN AREA HEIGHT
PROPERTYTAXACCOUNTPARCELN
ALLOWED PROPOSED ALLOWED PROPOSED
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EW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR t7
COMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑
❑ MIXED USE CHANGE OF USE Z
' ❑ PARKING LOT AREA PLANNING REVIEWED BY DATE
❑REMODELg
MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑
REPAIR ❑ CYDS
GRADING ❑ FENCE X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
z ❑GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ❑ ROCKERY FIREALARM
a(TYPE USE, BUSINESS OR ACTIVITY) EXPLAIN:
IL TYPE OFC NSTRUCTION CODE OCCUPANT R
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w NUMBER NUMBER OF
M OF ✓/ y DWELLING 1.�r SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES •L / UNITS r I LOAD
-� REQUIRED YES
DESCRIBE WORK TO BE DONE J
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T:) f L`-' Ci Li'ilC� SLS t �' Description FEE Description FEE
1 Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit � City Surcharge rj O
PLAN CHECK NO: Plumbing. Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical
It=
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC Grading
DONMAIN (CURBran
S; SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE g
j SEPARATE PERMISSION,
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
WIL PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
Ito
N "APPLICANT, ON BEHALF OF HIS OR HER SPOUSE; HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit U
w 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 # I
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
e 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
IN VIOLATION OF THE LABQA CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATI IN RANCE AND RCW 16:27. TOFSIG T RE DATE
SIGNYURE (OWNER 10
O GENT): DATE SIGNED (425) U,
-� Jr
771 =0220 RELEASED BY DAT
ATT EXT. 1333 TION Lj � O Gi 7
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL L"
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI• ORINAL ILE YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 I IBC110 I IRC110, PIN • OWNER GOLD - ASSESSOR
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Date Signature
l:lemp:bldg: fomes:ocapnFI 3/25/04'