20050573.pdfDATE RECE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MIAle, 5"14,eelp.
MAILING ADDRESS
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PLAT NAME/SUBDIVISION NO.
LOT NO�
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LID NO
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Required
E3
13
street use Permit Required
13
E3
EXISTING PROPOSED
Inspection Required
Sidewalk Required
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REQUIRED DEDICATION FT
underground
Winne required
METER SIZE
LINE SIZE
NO. OF FIXTWn
PRV REQUIRED
YESO NO13
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ADDRESS
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ALLOWED PROPOSED
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LOT COVERAGE
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REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
FRONT URSIDE REAR
PROPOSED
FRONT SIDE REAR
DO TION
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COMMERCIAL
COMPLIANCE OR
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MIXED USE
CHANGE OF USE
REMODEL
PARKING
REO'D PROVIDED
LOT AREA
PLANNING REVIEWED BY DATE
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SIGN
REPAIR El GRADING CYDS E] FENCE
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REMARKS
DEMOLISH TANK
OTHER
1 GARAGE RETAINING WALL
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ALARM
CARPORT ROCKERY'
FIRE
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NUMBER
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NUMIJER OF
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UNITS
SPECIAL INSPECTION
REQUIRED 1:1 YES
CONSULTANT
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
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GEOTECH REPORT
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Description
F EE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
LOT SLOP��
VESTED DATE
Building Permit
City Surcharge
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PLAN CHECK NO:
Plumbing
A
Base Fee
OC
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
2—
PERMIT APPLICATION: SEE ECDC 1 9.00.005(A)(5)
PERMIT LIMIT. SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
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'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY'AND
AIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
< ALL C RMIT SHALL NOT BE
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PE
0 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.,
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt 0
Landscapelnsp.
Total Amt. Due
Recording Fee
Receipt #
CALL
FOR INSPECTION.
APPLICATION APPROVAL
This application is not a permit until signed by the
Bu ilding Official at hisihor Deputy: and Foos are paid, and
receipt isacknowtodgrid in space provided
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE'TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRI.C.
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
DATE
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
(425)
771-0220
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SIGNATUR GEKr�\
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DATE SIGNED
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ATTE '11W ION USE OR OCCUPY A BUILDING OR STRUCTUR . E . UNTIL h)k L I JJJ
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL - FILE YELLOW - INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 f IBC110 f IRC110. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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