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it� ' �J PERMIT EXPIRES, -� • '
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ERMIT
CITY OF EDMONDS NUMBERr-
CONSTRUCTION PERMIT APPLICATION o13
DREss SUITEIAPT#
7
OWNER NAME/NAME OF BUSINESS
��� PLAT NAMEISUBDIVISION NO, LO O LID NO
Cu MAILING ADDRESS` LID FEE S
�) /j�/y -� u� �- PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved ❑
J RW Permit Required ❑
Sheet Use Permit Required Cl
CITY ZIP TELEPHONE EXISTING PROPOSED inspection Regmrotl ❑
J Sidewalk Requited ❑
Xw Underground 13 6fr/elh REOUIREDDEDICATION FT Wiring re uued ❑
NAtdFf METER SIZE LINE SIZE NO. OF FIXTURES I PRV REQUIRED
0
YES13 NO z
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ADDRESS REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE15
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CITY ZIP ITELEPHONE
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ENGINEERING REVIEWED BY
DATE
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FIRE REVIEWED BY DATE W
CITY ZIP TELEPHONE a
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STATECENN�JSE NUMBER EXPIRATION DATE D BY VARIANCE OR CU p�SHHORELINE O B� INSPECTION SEPA
�"'C� T�LU• q '' ✓' C3 YES It RED NO
COMPLETED EXEMPT
PROPERTY TAX ACCOUNT PARCEL 0..,J CA# ZONE SIGN AREA HEIGHT
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WAIVER D n ►A ALLOWED PROPOSE ALLOWED PROPOSED
/ Ot✓ O STUDY 0 / �/�I Lt
❑ NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGEREQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR . FRONT UR SIDE REAR c7
❑ COMMERCIAL COMPLIANCE OR N I) � NO LA
❑ ADDITION ❑ CHANGE OF USE z
r REMODEL ❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
MULTIFAMILY ❑ SIGN NOD PROVIDED O� l vL
REPAIR GRADING CYDS ❑ FENCE O 44
( X FT.) REMARKS O
1:1 DEMOLISH ❑ TANK ❑
OTHER � •
z ❑GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ❑ ROCKERY ❑ FIREALARM 11
a(TYPE OF USE, BUSINESS OR CTIVITY EXPLAIN:
rK TYPE OF TRUCTION CODE OCCUPANT
Livy) 3 GROUP
GNUMBER NUMBER OF
OF tJ DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
p STORIES !/ UNITS - LOAD
DESCRIBE WORK TO BE DONE REQUIRED YES
REMARKS i
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GEOTECH REPORT m
/ Jr BY:
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BY: .
t �U� VALUATION
$ t (
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Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: ,^ C ��J, 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
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
IL PERMIT LIMIT: SEE ECDC 19,00,005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Inspection
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire RBVIBW Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 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 1Z WD
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt #
I 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 This application is not a permit until signed by the
THE OWNER. I AGREE TO CO LY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL Building Official or his/her Deputy: and Fees are paid, and
TION; D IN DOING THE WO AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VI T NOF THE LA CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WOR COMP NSATI NS RANCE AND RCW 18:27,
F SIG RE DATE
IG RE (O R T): DATE SIEJED (425)el r I •l
7 771m0220 EL D Y DATE
A TENTI EXT. 1333
IT I UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL - FILE YELLOW 4NSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC1091 IBC110I IRC110. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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