20050583.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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UX MAILING ADDRESS
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ZIP TELEPHONE
NAME
ZIP ITELEPHONE
,.ower
CITY ZIP TELEPHONE
STATE LICENSE NUMBER EXPIRATI�" DATEMD BY
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PROPERTY TAX ACCOUNT PARCEL NO
j PERMIT EXPIRES
PERMIT
NUMBER (• C%�
JOB SUITE/APT#
ADDRESS oe
cJVUdy1PLAT NAME/SUBDIVISION NO LOT NO. LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL. STREET MAP TESCPApproved O
RW Permit Required 0
Sheet Use Permit Required E3
EXISTING _ __ PROPOSED Inspection Required O
Sidewalk Required I'
f1UlHgfWfla t 0
REQUIR D DEDICATION FT nn re uirntl O
METE S a y i.�IN S r tIndI( EQUIRED
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OWNERI O TE'tAC R fff° Sf I�L� PF5P r "aU6 A1TA E5
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ENGINEERI REVIEWED BY Ia ' DATE
listed expansion tank shall be
FIRE REVIEV fED BY DA w
UPC 608
VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REQ'D COMPLETED I EXEMPT
0 YES 0 NO
CA#
WAIVER pe B or L V a tDean does r"ulr (SRO osED
STUDY n rU amLOT{ LIC • V ��BB
RESIDENTIAL LREMARKS
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❑ NEW PLUMBING / MECH I JA
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❑ ADDITION COMMERCIAL ❑ COMPLIANCE OR —""" - _
❑ MIXED USE CHANGE OF USE " z
❑REMODEL ❑ KING LOT AREA PLANNING REVIEWED BY DATE g
MULTIFAMILY ❑ SIGN PROVIDED
FENCE " ST BE
REPAIR ❑ GRADING CYDS ❑
( X FT.) SpECTOR
DEMOLISH ❑ TANK ❑ OTHER By CITY pt
❑ CARPORT ❑ ROCKERY GE RETAINING WALL ❑ FFIRE IRE ALARM LERAREAUTS ALL NOT
(TYPE OF USE, BUSINESS OR ACTT ) EEXP�IN: BF AC T "-p �/►
c�SP Q(�$j� T10N GROUP OCCUPANT
NUMBER NUMBER OF. 11 `wor
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS LOAD
DESCRIBE WORK TO 13E DONE REQUIRED YES
REMARKS
GEOTECH REPORT
1 BY:
61 V1 61 r . STRUCTURAL DESIGN
BY:
, VALUATION
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S Description FEE Description FEE IT 5
u Plan Check Slate Surcharge
HEAT SOURCE f I LOT OPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: Plumbing 91W Base Fee
C THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
E DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
u PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION" Engr. IRSpeCllOn
Rim
'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
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection . Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE /w
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 # 1:7Q& try
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DILLY 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-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Oficial or know) edgediDeputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPL CTION receipt is acknowledged In space provided.
WORKMEN'S COMPENSAT NCE AND RCW 16:27.
OFFICIAL!�SIG ATURE 2DAE
SIGN R W ERO%GTl&* DATE IG/NED x(425)47/
7 / 1 0220 RELEASED BY DATE
ATTENTION 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. UBC109 ! IBC110 / IRC1106 PINK • OWNER GOLD - ASSESSOR
1010' PRESS BARD - YOU ARE MAKING 4 COPIES
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