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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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NAME
PERMIT EXPIRES I I
PERMIT —) l
NUMBERJOB
ADDRESS, �l � /� � �/) ��• SUITE��#
PLAT NAME/SUBDIVISION NO. c /LOT NO. LID NO.
LID FEE S
PUBLIC RIGHTOF WAY PER OFFICIAL STREET MAP TESCP Approved ❑
RW Permit RequE3Street Use Pcnnd red Requred ❑
EXISTING PROPOSED Inspection Required ❑
Sidewalk Required ❑
REQUIRED DEDICATION FT Underground ❑
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Wiring required ❑
METER SIZE LINE SIZE N0. OF FIXTURES PRV REQUIRED
YES O NO O t7
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE _
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STATE LICENSE NUMBER EXPIRATION ATE Y VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA m
r . / A / tM� REQ'D COMPLETED EXEMPT
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CA# ZONE SIGN AREA HEIGHT -1 'Tl
PROPERTY TAX AC O NT ARCEL NO.awl
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STUDY O 01k 18L IS•fs I�. g Ucfg 4-b0 Q
E] NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) m t,
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR t7 O
COMMERCIAL COMPLIANCE ORN z Q 0
❑ ADDITION ❑ CHANGE OF USE �' G N / k z C
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g m
❑ REMODEL ❑. MULTIFAMILY SIGN REO'D PROVIDED 'A i M Z
FENCE " JO
❑❑ GRADING ❑ C Z
REPAIR CYDS ( X FT.) EMARKS y•
OTHER G� DUV d 1 ► C� >. Mai DEMOLISH ❑ TANK ❑ � J } _
GARAGERETAINING WALL FIRE SPRINKLER (M l T' �--�
_ ❑ CARPORT ❑ ROCKERY ❑ FIRE ALARM au�,1 '� t^; g CL?F��/Q Q 'T1
n (TYPE OF USE, BUSINESS ACDEZ�
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TYP Of. O ST CTI�N C rz GROUP NT i
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m OF UNITS ING SPECIAL INSPECTION CONSULTANT LOOCAp PAN i 0 (n
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DESCRIBE WORK TO BE DONE
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STRUCTURAL DESIGN
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VALUATION D
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Description FEE Description FEE !n
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Plan -Check State Surcharge O
HEAT SOURCE LOT SLOPE°% VESTED DATE • r y.—
Building Permit City Surcharge ��j n
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PLAN CHECK NO: t,– 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 Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE g
SEPARATE PERMISSION. Engr. REVIEW
cc W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
d PERMIT LIMIT: SEE ECDC 19,00,005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION EngL Inspection
"APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
LLS 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 #
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,*
Recording Fee I Receipt #
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 permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL
TION:
Official or hislhor Deputy: and Foes aro paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged to space provided.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S M SATION INSURANCE AND RCW 19:27, OFF IALS SIGNA RE DATE
SIG RE ENT): DATE SIGNED (425) , cc:
771m0220 RE D BY TE
A TENTION EXT. 1333
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL L
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL • FILE YELLOW • I PECT R
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 / IBC110 I IRCIIU. PINK -OWNER GOLD - ASSESSOR
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