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DATE RECEIVED
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I PERMIT EXPIRES .1 it
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CITY OF EDMONDS
PERMIT
NUMBER
JOB
ADDRESS
SUITE/APT$;1
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
PLAT NAM EISUB DIVISION NO.
LOT NO.
LID NO
LID FEE S
MAILING ADDRESS
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?0 2
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Perinit Required
EXISTING —
PROPOSED
Street Use Perinil Requited
Inspection Required
Sidewalk Required
Underground
CITY ZIP
011 e-
L T�3'0201
TELEPHONE
REQUIRED DEDICATION
FT
Wiiinq required
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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TELE
NAME
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ADDRESS
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CITY
ZIP
ILAI/
I TELEPHONE
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`06
STATE LICENSE NUMBER
167 10)4
EXPIRATION DATE
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PROPERTY TAX ACCOUNtPA�CE NO.
51 11 .. P
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0 NEW
0 RESIDENTIAL
11
PLUMBING ir MECH
ADDITION
El
COMMERCIAL
1:1
COMPLIANCE OR
CHANGE OF USE
MIXED USE
.
REMODEL
MULTIFAMILY
F1
SIGN
REPAIR*
CYDS
E:i
FENCE x FT.)
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DEMOLISH
TANK
T7
0 HER
oGARAGE
CARP
RETAINING WALL
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FIRE SPRINKLER
FIREALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN-..
NUMBER NUMBER OF
OF DWELLING
STORIES UNITS
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I OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE
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VARIANCE OR CU I
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WAIVER 13
STUDY 12'
LOT COVERAGE
ALLOWED PROPOSED
PARKING
REO'D PROVIDED
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REMARKS
OF
SPECIAL INS TIO1
REQUIRE
I IN A REMARKS
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PLAN CHECK NO:
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS. DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
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
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
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-
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
WORKMEN'S COMPENSATWR*KSU RANCE AND RCW 18:27.
SIGNATURE (OWNER OR &ENTjj DATE SIGNED i
SHORELINE ORADBI
INSPECTION
SEPA
REQ'D -
M__
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COMPLETED
I
I EXEMPT
OYES No
ZONE
SIGN AREA
HEIGHT
ALLOWED PROPOSED
I
ALLOWED PROPOSED
PLS-12
1 �/14
11, �
:; "
I .7,
REQUIRED SETB . ACKS (FT.)
PROPOSED SETBACKS (FT.)
FRONT
SIDE REAR
FRONT
L/R SIDE REAR
10
1
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fVA
LOT AREA I
PLANNING REVIEWED 13Y
DATE
OCCUPANT
GROUP
CONSULTANT
OCCUPANT
LOAD
GEOTECHMEc 9 . m,/*( ' W I S '7�78 11,11Z
BY:
STRUC�,URft0E9IGN
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VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
LandscapeInsp.
Recording Fee
CALL
FOR INSPECTION
(425) C,
771-0220 �
ATTENTION X L I JJJ
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 I IRC110.
FEE
F/.f:::
Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
_Receipt # QZ re� U-7
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receiW is acknowledged in space provided.
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