20050550.pdf1
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAAMMEIIN�AMMEE OF BUSINESS
MAILING ADDRESS
CITY ZIP TELEPHONE
ADDRESS
ZIP ITELEPHONE
5 PERMIT EXPIRES
PERMIT C?7 G SSD
NUMBER
JOB SUITEIAPT#
AnnRFR' r
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP. TESCP Approved O
RW Permit RFAulmd 0
street Use Permit Requited 13
EXISTING PROPOSED Inspection Requited O
— _— sidewalk Required Q
REQUIRED DEDICATION FT a O
Wit
wrcm r . rmuit uved O
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NO O z
w
REMARKS w
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
9
A w
NAMt (n n 4F V
tY ENGINEERING REVIEWED BY DATE
o: ADDRESS
O
FIRE REVIEWED BY. DATE w
z CITY ZIP TELEPHONE LL
Oi
U
STATE LICENSE NUMB R' EXP RATION DATE CHEC ED BY ; "n L VARIANCE OR CU SHORELINE OR'ADB# INSPECTION SEPA
REQ'D COMPLETED EXEI IPT
OYES ONO
43
PROPERTY' TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT
�� j WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED
LU
.j 1 W l 3D6 STUDY O
1:1 NEW RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR t7
1:1COMMERCIAL COMPLIANCE OR z
1:1 MIXED
El CHANGE OF USE Z
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
13 REMODEL ❑ MULTIFAMILY
El SIGN REQ'D PROVIDED
FENCE
1:1 REPAIR REPAIR ❑ CYDS ❑ ( X FT.) REMARKS
❑ DEMOLISH TANK ❑ OTHER
Z 1:1GARAGE RETAINING FIRE
CARPORT ❑ ROCKERY WALL ElFIREALARM SPRINKLER
a (TYPE OF US USINESS R ACTIVI XPLAIN:
TYPE GL f ONSTRUCT ON CO OCCUP
v GROUP IV
LU NUMBER =NG
OF SPECIAL INSPECTION CONSULTANTOCCUPANT
p STORIES - LOAD
-� REQUIRED 13 YES
DESCRIBE WORK TO BE DONE
REMARKS. O
do z0
GEOTECH REPORT m
BY:
STRUCTURAL DESIGN
BY: .
VALUATION
$
OOOF
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT 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
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE Grading
SEPARATE PERMISSION, EngL R@VIEW
w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00,005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Inspection
(111 H •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
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
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
G 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/tier Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowl Iged in space pro ided
IN VIOLATION OF THE LAB O ODE OF THE STATE OF WASHINGTON RELATING TO
WORK EN'S MPENS S NCE AND RCW 18:27. FFI L GI AT RE DAT
All Af
1 R GATE SIGN (425):55
771 -0220 RELE E BY DAT
TTE N 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 • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC1091 IBC110 / IRC110. PINK • OWNER • GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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