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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
ER NAMEINAME OF BUSINESS
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CITY
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NAME
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ADDRESS
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STATE LICENSE I
110
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NEW
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ADDITION
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REMODEL
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REPAIR
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DEMOLISH
❑GARAGE
CARPORT
ZIP TELEPHONE
QW0 I W5)775-
�j PERMIT EXPIRESPERM
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JOB SUITEIAPT#
ADDRESS �
PLAT NAM EISUBDIVISION NO. LOT NO. LID NO,
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved ❑
RW Permit Required ❑
Street Use Permit Required ❑
EXISTING PROPOSED Inspection Required ❑
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Sidewalk Rogwretl[3anrgru [3REQUIRED DEDICATION FT Wirinorequired
❑
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NO13 K
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REMARKS w
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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V ENGINEERING REVIEWED BY DATE
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ZIP FIRE REVIEWED BY DATE w
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ER EXPIRATION DATE CHECKED BY VARIANCE OR ClJ SHORELINE OR ADB# INSPECTION SEPA
_ REQ'D COMPLETED EXEMPT
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CA # T' 1 ZONE SIGN AREA HEIGHT
INT PARCEL NO.
0 - �$^ � 1 21 d•1 WAIVE O �/ / ALLOWED PROPOSED ALLOWED PROPOSED
STUDY
RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRO T UR SI E REAR
❑ COMMERCIAL COMPLIANCE OR 3� < 35 j � '� S +��0, f �-� Z
❑ MIXED USE ❑ CHANGE OF USE ✓ z
PARKING LOT AREA PLANNING REVIEWED BY DATE a
❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED 0 / OJ
❑ GRADING ❑ FENCE !�/
CYDS ( X FT.) REMARKS
❑ TANK V PATIO
RETAINING WALL FRE SPRINKLER O 000[
z ❑ ROCKERY ❑ FIREALARM
IL(TYPE OF USE, B SINESS OR ACTIVITY�EXPLAIN: I. cAnq:> 004 C Fe0eAe 04 71 D.
r �1. �/1. C IL TYPE OF CONSTRUCTION CODE OCCUPANT
v DC7 E /� /9� GROUP 3
Lu NUMBER NUMBER OF /' V
OF. DWELLING / SPECIAL INSPECTION CONSULTANT OCCUPANT
p STORIES UNITS LOAD
REQUIRED O YES
DES RIBE WORK TO BE DO
REMARKS a
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�• GEOTECH REPORT m
BY:
STRUCTURAL DESIGN
BY.
VALUATION
fr I I CGT(�x. Description FEE Description FEE
Plan Check Stale Surcharge `��
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee f
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO V N Y I LT
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC'
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE Grading
t SEPARATE PERMISSION.
IN- Engr. Review
99 PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
LU
d PERMIT LIMIT: SEE ECDC 19.00,00S(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
•APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposita4 I
Uj 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 # S
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY `
FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE f�
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt, Due LJ
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee ff Recoipt N
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 DULY AUTHORIZED AGENT OF This application is not a pormd unlit signod by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALLBudding Official or hislhur Doputy and rues aro ph d. Ind
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 reeeipl is eeknowludpnd m space provided
FOR INSPECTION
WORKMEN'S COMPENS RANCE AND RCW 18:27, OFFICIALS SIGNATURE DATE /
TOUR NER AGE DATES NED (425) /�
• - S 3 OS 771=0220 RELEA, DA E.
ATTENTION EXT9 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- RIGINALg . YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 I IBC110 / IRC110. PINK' • 0m GOLD • ASSESSOR
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City of Edmonds
All persons Are Ordered to
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t '[ We are- unable to locate a valid errnrt for the.work bemg,done at/this address. A permit 1:: e Z
;'is required rgject'_ Work"SHALL NOT'continue until a; ;ermitlhas been obtained , D
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and ahe ,work ins ected for;' conformance with`4applicable '.codes and ordinances If you c
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z�r['1 have` alread V` yobtamed ;the :. ermtt lease: contact us at (425) 771
'0220-,o,ith the ermrtIt
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number so we can revise our records ,,
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(t� An:a hcat><on must:be submitted=or a response in writ><ng ;, ;uf o ,-
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must lbe made to our< office no later than
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4:00 pm on
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VIOLATI1 +1ON FEE EQUAL .OR UP TO FIVE TIMES r rn
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BE ASSESSED.`
{ ;? M :, THE PERMITt`,FEE SHALL :i r4
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Posted this ;O day of Gl�i�IST to I
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t� Warning: The failure to stop this `work -or activity and%or the
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resuming of work without permission or the 'remOVal,
mutilation, or concealment of this Notice is punishable by fine
and imprisonment.
City of Edmonds Development Services Department Building Division
121 5"' Ave N • Edmonds,:WA 98020 • (425) 771-0220 I
Office Hours M -F 9-12 and 1=4