20050687.pdfDATE RECEIVED r` y
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
ADDRESS
ZIP
(`�I`'✓ PERMIT EXPIRES !/ /
PERMIT /)
NUMBER _�//��
JOB SUITEIAPT#
ADDRESS
PIAT NAMEISUBDIVISION NO, LOT NO LID NO
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPAppruved O
RW Permit Requited C3
EXISTING PROPOSEDStreet use Permit Required E3
Inspection Required E3
Sidewalk Requited 0
REQUIRED DEDICATION FT Underground O
-- Wem ro uenu CI
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NO O Z
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE X
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Zoll T I.7 7 G "R}CT ( I 1 V •" ENGINEERING REVIEWED BY DATE
ADDRESS
MON 3 (001"Ilij FIRE REVIEWED BY DATE
CITY ZIP TELEPHONE
L YNNw 01519 957337 q2- 775 -� �F�� LL
STATE LICENSE NUMBER EXPIRATION DATE C ECKE Y VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
n�A1� i I c) Ljtj I jI� r i�iO� / r l .0 YES 13NO COMPLETED EXEMPT
PROPERTY TAX ACCOUNT PARCEL NO. l [[[�� CA# ZONE SIGN AREA HEIGHT
WAIVER 0 ALLOWED PROPOSED ALLOWED PROPOSED
STUDY O
❑ NEW ❑ RESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED. FRONT SIDE REAR FRONT L/R SIDE REAR
COMMERCIAL COMPLIANCE OR ?
❑ ADDITION ❑ MIXED USE ❑ CHANGE OF USE i
❑ REMODEL ❑ ❑ PARKING
LOT AREA PLANNING REVIEWED BY DATE a
MULTIFAMILY SIGN REQ'D PROVIDED
GRADING FENCE
❑ REPAIR ❑ CYDS ❑ ( X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
❑
CARPORT ❑ ROCKERY WALL ❑ FIRE ALARM SPRINKLER
(TYPE OF USE, BUSINESS OR IVIT ) ��
EX IN:
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(/ TYPE N TRUCTIO E OCCUPANT
GROUP I
NUMBER NUMBER OF
OF IDWELLING I SPECIAL INSPECTION CONSULTANT OeCL
STORIES ' UNITS 1 V LOAD
DESCRIBE WORK TO BE DONE REQUIRED YES
REMARKS t 61161
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Cp INSPECTOR
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NOT.
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STRUCTURAL DESIGN.
BY: ACCEPTED
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VALUATION
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Description FEE Description FEE
Plan Check Stale Surcharge
HEAT S URCE LOTSLOPEVESTED DATE
.Building Permit City Surcharge
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
f DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE Grading
SEPARATE PERMISSION.
Lu PERMIT,APPLICATION: SEE ECDC 19.00,005(A)(5) Engr. Review
a PERMIT LIMIT: SEE ECDC 19.00,005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
V) *APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
ud IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
z EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
Q ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
= FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE r
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 BeFReceipt # ��✓f��
IH EREBY 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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC•This application Is not a permit unlit Signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Fees 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 COMPENSAT190 INSURANCE AND RCW 18:27,
1. OFF� I L�G AjUR j DATE
SI: RE (OWNER OR DATE SIGNED
(425) �! /�
- 41Irooli771 0220 REL ASED BYV ! DATE
ATTE ION 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-
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 / IBC110 / IRC110. ORIGINAL -FILE YELLOW -INSPECTOR
PINK -OWNER •GOLD •ASSESSOR
101" PRESS HARD as YOU ARE MAKING 4 COPIES
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