20050511.pdfC �" �/� JC1CC •_� /I! •' r�j.. i�L''J�..• r` DATE RECEIVED '
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILINGADDRESS
CITY ZIP /TELEPAONE
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PERMIT PERMIT EXPIRES
PERMIT
NUMBER
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ADDRESS �,(,' SUITEIAPj#
PLAT NAMEISUBDIVISION NO. LOT NO. LID NO
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved Q
RW Permit ReQuited 0
Street Use Permit Required E,
EXISTING GPROPOSED Inspection Required
w Sidewalk Regwrod If
S REQUIRED DEDICATION FT Wmm Underground.O
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METER SIZE _ LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NO O z
REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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CITY ZIP TELEPHONE
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NAME y /�� ,I� ` CBL#
ADDRESS
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STATE LICENSE NUMBER EXPIRATION DATE ECKE Y
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PPEUTYTAX ACFO T. PARCEL NO.
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❑ NEW ❑ RESIDENTIAL ❑ PLUMBING I MECH
ErCOMMERCIAL COMPLIANCE OR
❑ ADDITION ❑
MIXED USE
CHANGE OF USE
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REMODEL ❑ MULTIFAMILY ❑ SIGN
C] REPAIR ❑ GRADING CYDS ❑ FENCE X FT.)
❑ DEMOLISH ❑ TANK 1:1OTF !4 SC',llq
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CARPORT ❑ RO KGARAGE IE Y WALL ❑ FIRE FIR/FIREALARM SPRINKLER
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE W
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
�^ ''``''11 REQ'D COMPLETED 155ZT
��1►.� �� . i YES ONO /V\
CA# ZONE SIGN AREA HEIGHT
WAIV ALLOWED PROPOSED ALLOWED PROPOSED
STUD (•I ^' r• t L ;2 i
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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No Cw c:" i
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PARKING LOT AREA PLANNING REVIEWED BY DAT g
REQ'D PROVIDED
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NO � W
REMARKS
�j TYPE OF CONSTR TION CODE OCCUPANT
NUMBER NUMBER OF
V �6 � GROUP
OF DWELLING /r SPECIAL INSPECTION CONSULTANT OCCUPAN
> STORIES UNITS '!/ LOAD
a REQUIRED D YES
DESCRIBE WORK TO BE DONE ^
A T REMARKS z
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i GEOTECH REPORT
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• n STRUCTURAL DESIGN
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VALUATION
Description FEE Description FEE
Plan Check State Surcharge ,f�� •S >
HEAT SOURCE LOT SL PE% VESTED DATE
�j%J-} Building Permit L v City Surcharge %s
PLAN CHECK NO: Plumbing Base Fee g s
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
fDONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
� Engr. Review
z PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
i 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
z EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
a ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
= FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
0 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt, Due % r
0 NOR LIMIT IN ANY 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. CALLBuilding 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 LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged In space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. OFFICIALS SIGNATURE DATE
SIGNATURE (OWNER ORA NT �� DATE SIGNED
(425) / --
-7 / c
771 -0220 RELEA Y DATE
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A ENTION 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 -INSPECT
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109It IBC110 1 IRC1101 PINK -OWNER GOLD - ASSESSOR
.10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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