20050543.pdfDATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME O BUSINESS
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CITY ZIP TELEPHONE
NAME
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CITY ZIP TELEPHONE
/PERMIT EXPIRESPERMIT
NUMBERG'D�'�L�
JOB SUITE/APT# 'A/ADDRESS
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PLAT NAMEISUBDIVISION NO. LOT NO, LID NO.
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved ❑
RW Perme Required ❑
Street Use Permit Required ❑
EXISTING PROPOSED Inspection Required ❑
Sviewalk Requited ❑
REQUIRED DEDICATION FT Underground ❑
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wiring re wrod ❑
METER SIZEI ' (hI�D)F €i�ETGlif#>;►: iD PRV REQUIRED
• STI'REEI O BE CLEANED s 17 W
REMARKS w
OWNER/CONTRA®ORJS%VMEf�1 TCfj U CtKFW. ff. ATZ
LINE W
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•WATER METER TO BE REMOVED OR
NAME CBL# ,F
0 T11iM 439 DUMP
LSIL ENGINEERING REVIEWED BY
o ADDRESS3 , / SEE DEMOLITION INSPECTION
It late le er !� FIRE REVIEWED BY FOR INSPECTION REQUIREI'vSLDAT�S it
z CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE CKE BYE
OR CU SHORELINE ORADB# INSPECTION SEPA
C pry ` REO'D COMPLETED EXEMPT
SJ 6lv'r k0 � �� 4 DYES ONO
a PROPERTY TAX ACCOUNT PARCEL NO. ZONE SIGNAREAHEIGHT9 ALLOWED PROPOSED ALLOWED PROPOSED
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❑ NEW RESIDENTIAL ❑ PLUMBING I MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIR SIDE REAR O
COMMERCIAL COMPLIANCE OR
ADDITION ❑ CHANGE OF USE Z
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑❑GRADING ❑ FENCE X FT.) REMARKS
REPAIR CYDS
EMOTHER
OLISH 1:1GARAGE TANK ❑
_ ❑ CARPORT ❑ ROCKERY NING WALL ❑ FIRE ALARM FIRE LER
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
u f, TYPE F CONSTRUCTION COPE OCCUPANT f�
GROUP
W NUMBER NUMBER OF . '
OF / DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
O STORIES UNITS LOAD
-� REQUIRED 13YES
DESCRIBE WORK TO BE DONE
REMARKS i
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l;q-erh//S/�/ /1 �� �7�� GEOTECH REPORT m
a--- / BY:
STRUCTURAL DESIGN
BY:
VALUATION,
Description FEE Description FEE
F .
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE �•
Building Permit L City Surcharge
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO MBChanIC01
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
I= SEPARATE PERMISSION.
,(� Engr. Review
PERMIT APPLICATION: SEE ECOC 19.00.005(A)(5)
ii PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection ~-
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
In "APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit .
Uj IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
i EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
dg 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 # > ��
1 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 LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTIONMRELEA
receipt is acknowledged In space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. SIGNA U DAT
SIGNATUR NER 0 G NT): DATE SIGNED (425)
771 -0220 D BY 1 D
ATTENTION EXT. 1333 r--'
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 if IBC110 I IRC110. PINK -OWNER GOLD - ASSESSOR
101" PRESS HARD = YOU ARE MAKING 4 COPIES*
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