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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS Lv'fl��`1,
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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ADDRESS
PERMIT EXPIRES
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NUMBER.JOB
ADDRESS i SIJ EIAPT'
PLAT 14AMEISUBDIVISION NO. LOT NO. LID 40.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved ❑ i
RW Permit Required ❑
Street Use Permit Required ❑
EXISTING PROPOSED Inspection Required ❑
Sidoealk Required ❑
REQUIRED DEDICATION FT Underground ❑
Wiring required ❑
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES I3 NO O O
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REMARKS w
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE z
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NAME ` , CBL#
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r, / ENGINEERING REVIEWED BY DATE
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CITY TELEPHONE FIRE REVIEWED BY DATE w
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STATE LICENSE: EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADBI INSPECTION REO'D COMPLETED EXEMPT L>r? % 1 V 1 R d YES 13 NO SEPA
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PROPERTY TAX ACCOUNT PARCEL NO. CAtI 20NE SIGN AREA HEIGHT
2 '� WAIVER f] ALLOWED PROPOSED ALLOWED PROPOSED
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RESIDENTIAL LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) C m
❑ NEW ❑ PLUMBING / MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR O rn O
COMMERCIAL COMPLIANCE OR z
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❑ = n
MIXED USE CHANGE OF USE z 0 C
❑ PARKING LOTAREA PLANNING REVIEWED BY DATE
REMODEL g
MULTIFAMILY 13 SIGN REQ'D PROVIDED = m
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REPAIR CYDS
❑ ❑ GRADING ❑ FENCE X FT.) REMARKS
10 owsoll
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❑ DEMOLISH ElTANK 11OTHER r wool
z ❑GARAGE RETAINING WALL FIRE SPRINKLER _
CARPORT ❑ ROCKERY ❑ FIRE ALARM
a(TYPE OF USE, BU 1NESS CTIVI EXP 01 I O T
U / TYPE OF T C E OCCUPANT ")
�% GROUP 3 x
OF
w NUMBER / NUMBER OF �-/ _ M
OF / DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT IT! rn
O STORIES iii UNITS1t4 LOAD to
-� REQUIRED DYES
DESCRIBE WORK TO BE DONE m
REMARKS z C
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GEOTECH REPORT m Z
BY: "i
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BY:
VALUATION
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Description FEE Description FEE ?
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Plan Check State Surcharge ZO�
HEAT SOURCE LOT SLOPE% VESTED DATE �� •
Building Permit City Surcharge !% n
PLAN CHECK NO: Plumbing Base Fee rTl
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE g
SEPARATE PERMISSION. Engf. RBVIBW
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 Engr. Inspection
i
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire ReV10W Plan Chk. Deposit
ul IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF '
CEDMONDS, 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
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapelnsp. Total Amt. Due
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
Recording Fee Receipt # G
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 permd until signed by the
THE OWNER. r 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 Budding reOffceipt
i or his/her Deputy and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION rewlpt is acknowledged m space provided
WORKMEN'S COMPENSATYWRYURANCE AND RCW 18:27. OF IAL IGNR DATE
SIGNAT RE (OWNER O AGENT) P (425) '
DATE SI NED
72
65: 0S `.� .goo
771-0220 �E Y'
TENTIO 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 IBC910 / IRC1101 PINK -OWNER GOLD -ASSESSOR
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