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CITY OF EDMONDS NUM IER -� D
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
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OWNER NAME/NAME OF BUSINESS o' T i'1(> [`'' 1Ci'7 !•��.I , �)i r('(? N/IV.*Irri s' �/V i l
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
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W MAILING ADDRESS LID FEE
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4/20. S to 1 W f � ' RW Permd Required 13
CI ZIP- Sheet Use Permit Required C
{� (IP (� ELEPHONE-I••�_(�+� EXISTING _ PROPOSED Inspection Rogwmd O
;1..& We � V (V? A. �4 � I ? J V ^ _ •/ _ �` Sidewglk Required O
�2b,J� 7 REQUIRED DEDICATION FT MindUndergroundrequired
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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STATE LICENSE NUMBER (/ ) �^' EXPIRATION DATE C��OECKED Y VARIANCE OR Cu SHORELINE OR ADB# .I/NSREO D PECTION SEPA 0
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PROPERTY TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT _
I / WAIVER 13 ALLOWED PROPOSED ALLOY/ED PROPOSED I L -•I TI
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NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT. rn
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR j C
ADDITION
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MIXED USE CHANGE OF USE Z Q
PARKING LOTAREA PLANNING REVIIEEWWEEDt BY DATE g C
❑ REMODEL ❑ MULTIFAMILY ❑ FENCE SIGN REQ'0 PROVIDED �— / �Nu-/Ti ' a I X Z ,
❑ REPAIR ❑ GRADING ❑ G/,
CYDS ( X FT.) REMARKS p �11
❑ �1✓1 I D0 OTNYj�VDEMOLISH TANK z
❑GARAGE RETAINING FIRE
CARPORT ❑ ROCKERY WALL ❑ FIREALARM SPRINKLER
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L (TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN: O
TYPE QF CONSTRUCTIONCODE OCCUPANT
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u NUMBER NUMBER OF v _
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT ITI M
STORIES UNITS �l/ LOAD
DESCRIBE WORK TO BE DONE REQUIRED 0 YES O
REMARKS i C M
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Description FEE Description FEL�E
Plan Check State Surcharge w' z
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HEAT SOURCE LOT SLOPE% VESTED DATE �� O
Building Permit City Surcharge ` '•I
PLAN CHECK l r` � Plumbing Base Fee ` m
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED,
THIS PERMIT COVERS WORK TO Mechanical
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)
L PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr, Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
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
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.'
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Recording Fee Receipt #
1 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
THE OWNER, I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is not a permit until signed the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Fees aro p paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged m space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 19:27,
OF I N RE DATE
(OW R O GEN DATE SIGNED) (425)
f / L —v 771 m0220 REL ASED BY DATE
ATU 9E
ATTENTION EXT. 1333 Ct
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 I IBC110 I IRC110, ORIGINAL •FILE •YELLOW NSPE oR
PINK -OWNER •GOLD -ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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ro 8403 Main Street Corporate Office: 4206 5tone Way N. Seattle, WA 98103
g Edmonds, WA 98020 (l'1� I_nlh•, Phone (206) 634-.1356 Fax (206) 634-1357
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