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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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NUMBER
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❑ NEW
❑ ADDITION
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[PERMIT EXPIRESPERMIT 5
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NUMBER-1�7
JOB SUITE/APTN
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PLAT NAME/SUBBDIVISIIOON NO. NO. LID NO. Y
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved ❑
RW Permit Required ❑
Street Use Permit Required ❑
EXISTING PROPOSED Inspection Requited ❑
Sidewalk Required ❑
REQUIRED DEDICATION FT underground DWinno required ❑
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 13 NO f7 z
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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ENGINEERING REVIEWED BY DATE
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HONEFIRE REVIEWED BY DATE U,
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EXPIRATION DATE ED BYIMM11i"'11
VARIANCE OR CU SHORELINE 0 DB INSPECTION SEPA
1 �A`7 (�APP ( I O YES'A NO CJfdPLETED I E%EA1PT
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❑ RESIDENTIAL ❑ PLUMBING / MECH
❑ COMMERCIAL COMPLIANCE OR
❑ MIXED USE ❑ CHANGE OF USE
MULTIFAMILY ❑ SIGN
❑ GRADING❑ FENCE
CYDS ( X
❑ TANK ❑ OTHER
❑RETAINING WALL FIRE SPRINKLER
ROCKERY ❑ FIRE ALARM
CA# ZONE SIGN AREA HEIGHT
WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED
ID
STUDY 13 I �• 0 Z1j 1 L.?�
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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PARKING LOTAREA PLANNING REVIEWED BY. /hT DATE g
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FT.) REMARKS ►`110 Lkt�` U NT0
TYPE OF CONSTRUCTION CODE OCCUPANT
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NUMBER NUMBER OF /) n
OF % DWELLING C!/ SPECIAL INSPECTION CONSULTANT OCCUPANT
0 STORIES UNITS LOAD
DESCRIBE
DESCRIBE WORK TO BE DONE REQUIRED 131
REMARKS t,
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GEOTECH REPORT
STRU TU L D SIGN
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VALUATION
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Description FEE Description FEE.
Plan Check jq State Surcharge JV
HEAT SOURCE LOT SLOPE% VESTED DATE' `
Building Permit r City Surcharge < J
PLAN CHECK NO:-390
Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC.
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
t SEPARATE PERMISSION.
� Engr. Review
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
91 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit r'
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M 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 —�
Qj 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 # 14
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT 1 AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
he
THE OWNER, I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is not a permit until signor p id.
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or acknowledged
Deputy: and Fars are paid, and
IN VIOLATION OF THE LARR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSAFIO.N1141URANCE AND RCW 16:27,
LSTURE DATE
SIG=E ( MONT DATE SIGNED (425)
771 0220 RVA:elBY z le
DAT
A TEN ON EXT. 1333 ' L
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL r
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL FILE YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC1101 PINK -OWNER GOLD - ASSESSOR
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