20050861.pdfI -'I DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILINGADDRESS
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CITY ZIP TELEPHONE
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ADDRESS
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PERMIT EXPIRES
PERMIT
NUMBER
JOB
ADDRESS AW
PLAT NAM EISUBDIVI SION NO. LOT NO. LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved [3
RW Permit Requited E3
Street Use Permit Required 13
EXISTING PROPOSED Inspection Required El
Sidewalk Recluired 13
0
REQUIRED DEDICATION(�4� F�' n n','ad E3
METER SIZE BhWE:81?1r�) ;-V%,NyftF
YTIM QUIRED
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OWNER/CONTRACTOR RESPONSI lel OUDRAINAGE
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ENGINEERING REVIEWED BY
DATE
ADDRESS
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FIRE REVIEWED BY
DATE
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CITY ZIP
TELEPHONE
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STA EXPIRATION DATE
'Vt LICENSE NUMBER
I CHECKECLAY
VARIANCE OR CU
SHORELINE ORADE10
INSPECTION
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SEPA
COMPLETED
EXEMPT
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SIGN AREA
HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO.
WAIVER 13
1
ALLOWED PROPOSED
1 1
ALLOWED PROPOSED
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STUDY 13
,
NEW
%RESIDENTIAL
LUMBINIICI MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT LJRSIDE REAR
ADDITION
n COMMERCIAL
COMPLIANCE OR
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MIXED USE
CHANGE OF USE
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REMODEL
SIGN
PARKING
REO'D PROVIDED
LOT
AREA
PLANNING REVIEWED BY DATE
El MULTIFAMILY.
GRADING FENCE
REPAIR CYDS X FT.)
REMARKS
1:1 DEMOLISH El TANK OTHER
GARAGE RETAINING WALL FIRE SPRINKLER
FIREALARM
CARPORT ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITYA)PLAIN
TYPE 0 TICIpt
OCCUPAN
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J�&,UDE
GROUP
NUMBER
NUMBER OF
190A
OF
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SPECIAL INSPECTION
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CONSULTANT
OCCUPANT
STORIES
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REQUIRED OYES
LOAD
DESCRIBE
WORK TO IJE DONE
REMARKS
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GEOTECH REPORT
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STRUCTURAL DESIGN
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VALUATION
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Description
FEE
Description
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FEE
Plan Check
State Surcharge
EAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON P . RIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
Grading
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
r PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 119.00.005(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. Deposi
Al
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
E EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection.
Receipt #
r ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
cc
r FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
3 CE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINAN
Landscape Insp.
Total Amt. Due
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.0
fReceipt
Recording Fee
#
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 COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
Building Official or his/her Deputy: and Fees are paid, and
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
FOR INSPECTION
receipt provided
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WORKMEN'S COMI?fNSATION INSURANCE AND IRCW 18:27.
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(425)
NLIAS ;E1
SIGNATUR!!: R AGENT):
DATE SIGNED
771-0220
RE 0
ATTENTIOW t:A L 1JJJ
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 if IBC110 / IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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