20050666.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
CITY wO:ZIP TELEPHONE rr
NAME
ADDRESS
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1 7 PERMIT EXPIRES
PERMIT , /
NUMBER �o� IJ - i '/�
JOB SUITE/APT#
ADDRESS
PLAT NAMEISUBDIVISION NO. LOT NO. LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP IMP Approved O
RW Permit Required E3
Street Use Permit Required 13
EXISTING __.._/ PROPOSED Inspection Requend
Sidewalk Requited
REQUIRED DEDICATION FT' Underground O
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METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
- YES 13 NOM 2
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REMARKS w
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE _
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CITY ZIP TELEPHONE' 1 V-> V
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NAME CBL#
�W ! ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE
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CITY ZIP TELEPHONE 0:
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STATE LICENSE NUMBER EXPIRATION DATE C y VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
RE 'D COMPLETED EXEMPT
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CAN ZONE SIGN AR r HEIGHT
PROPERTY TAX ACCOUNT PARCEL WAIVER kLOWrn P OPO D ALLOYIED PROPOSED
OD STUDY O Q
W R7F ESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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COMMERCIAL COMPLIANCE OR + z
❑ ADDITION ❑ MIXED USE ElCHANGE OF USE i
❑REMODEL PARKING LOT AREA PLA G REVIEWED BY DATE g
❑ MULTIFAMILY 1 SIGN REO''D PROVIDED Q a
cc A
❑ REPAIR ❑ GRADING CYDS ❑ ENCE X FT.) REMARKS
❑ DEMOLISH ❑ TANK 1 L3
OTHER
❑, CARPORT ❑ ROCKERY GARAGE G WALL. ❑FIREALARM IRE LER
TYP O T CTI N OCCUPANT
i`� GROUP
61 La-Av
NUMBER NUMBER OF v
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES ( UNITS LOAD
DESCRIBE W RK TO BE DON REQUIRED YES
REMARKS _
Ira rox Aumh 0
GEOTECH REPORT
BY; m
STRUCTURAL DESIGN
BY:
VALUATION
$
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE Gam^"
Building Permit City Surcharge I
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,
Engr. Review
u PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
L PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
'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
E EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
e ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
E 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 #
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 hls/hor Deputy: and Foes aro paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LAB ODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged In space provided
WORKMEN'S COMPENSAT S ANCE AND RCW 18:47. 0 FI A SIGNATURE DATE
SIGNATLI (OWNER OR -N ► DATE SIGNED (425) �ZZ
c /� C �_ b / 71 -0220 REL BY DATE .
ATT TION EXT. 1333 (@ I/
IT IS U LAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL.
A FIN L INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL FILE & YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 I IBC110 1 IRC1104 PINK
o NEH • GOLD • ASSESSOR
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
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