20050668.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
CITY ZIP TELEPH IVE
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NAME
PERMIT EXPIRES t>< I `I UI�J
PERMIT
NUMBER
JOB SUITEIAPT#
ADDRESS
PLAT NAME/SUBDIVISION.NO. LOT NO \ LID NO
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved O
RW Permit Required 0
Street
EXISTING �7 PROPOSED spectiRequired on Required 0
inspection
!-_---_— Sidewalk Required 0
REQUIRED DEDICATION FT Underground 0
Minnrequired 0
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NO O Z
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REMARKS i
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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CITY ZIP- mo•'•,' I
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
fv%i ID j REQ'D COMPLETED E%EAIPT
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113YES 13 NO
PROPERTY TAX ACCOUNT PARCEL NO. CA# / ZONE SIGN AREA HEIGHT
0.�Q� A ^ . WAIVE ALLOWED PROPOSED ALLOWED PROPOSED
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❑ NEW ❑ RESIDENTIAL ❑ PLUMBING I MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
COMPLIANCE OR
❑ COMMERCIAL
❑ ADDITION ❑ MIXED USE ❑ CHANGE OF USEz
PARKING LOTAREA PLANNING REVIEWED BY DATE g
❑ REMODEL MULTIFAMILY ❑ SIGN REQ'D PROVIDED a
❑ REPAIR ❑ GRADING 13FENCE
CYDS ( X FT.) REMARKS
DEMOLISH ❑ TANK ',/
OTHER ` CL L
r ❑GARAGE RETAINING WALL FIRE SPRINKLER c).S I. oyiUA
CARPORT ❑ ROCKERY 13 FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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TYPE OFFjjlT/QN COUE GOCCUPA
ROUP NT
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uNUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OC tU7PANT
STORIES UNITS LOAD
DESCRIBE WORK TO BE DONE REQUIRED D YES
REMARKS z
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A Y14\ V.0�xf GEOTECH REPORT m
BY:
STRUCTURAL DESIGN
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$
Description FEE Description FEE
Plan Check State Surcharge 15 t
HEAT SOURCE LO SLOPE% VESTED DATE
C� �t+ �- Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical UNIX
C BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading IGO
t SEPARATE PERMISSION.
s Engr. Review
Lu PERMIT APPLICATION: SEE ECDC.19.00.005(A)(5)
4 PERMIT LIMIT: SEE ECDC 19.00,005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION l ,
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review P�ac�6Fik 6epvsit .
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 # a
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 Landscape Insp. Total Amt. Due
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION
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Recording Fee Receipt # C
1 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
THE OWNER, 1 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/her Deputy: and Foes are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided
WORKMEN'S CO SATI SURANCE 2 RCW 18:27,
O IAL N T RE DATE
SIGN A/Vif
� DATE SSIG ED �j•� �L�25, r ,�C'
o Q9 (� fi�� / 71 -022 RELE SE Y w )ATC
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ATTENTION EXT. 1333
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 I IBC110 i IRC110• ORIGINAL � NI71 GOft ow S5E(INSP;S TOR
PINK • OWNCIt GOLD ASSCStiUIi
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