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DATE RECEIVED
PERMIT EXPIRES
PERMIT ! 6
CITY OF EDMONDS NUMBER --
CONSTRUCTION PERMIT APPLICATION gDDRESS UITEIAPT#
OWNER NAME/NAME OF BUSINESS
PLAT NAME/SUBDIVISION NO LOT NO. LID NO
W MAILING ADDRESS LID FEE S
Z TESCv rov
3 PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP App 0
° ��•RW Permit �� steetUse Permit rRequited 13
CITY ZIP TELEPHONE EXISTING PROPOSED Inspection Requited O
Sidewalk Required 0
Underground
REQUIRED DEDICATION FT Winne
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Wrtme required
uitued O
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
U YES 13N0 13 z
It= ADDRESS REMARKS w
L) OWN ERIC ONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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CITY ZIP TELEPHONE
NAME d CBL#
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v (W' ENGINEERING REVIEWED BY DATE
ADDRESS
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FIRE REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATION 0 TE Cl- CKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
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OYES 13 NO COMPLETED I EXEMPT
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PROPERTY TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HE
¢ WAIVER D ALLOWED PROPOSED ALLOWED PROPOSED
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Wi STUDY 13
IF
❑ NEW ❑ RESIDENTIAL ❑ PLUMBING I MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE . REAR FRONT UR SIDE REAR
COMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑ MIXED USE ❑ CHANGE OF USE E
PARKINGLOT AREA PLANNING.REVIEWEDBY DATE g
REMODEL ❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED a
El ❑ FENCE X' FT.) REMARKS
REPAIR CYDS
❑ DEMOLISH ❑ TANK ❑ OTHER
Z ❑GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ❑ ROCKERY f4Rt'_ htYtR V
n(TYPE OF USE, I SS OR AC IVIT ) EXPLAIN:
TYPE OF CONSTRUCTION CODE OCCU GRT
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I w NUMBER NUMBER OF
OF DWELLING�� SPECIAL INSPECTION. CONSULTANT O CUPANT
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REQUIRED YES
DESCRIBr E WORK TO BE DONE �y�l
: G G`.•/�7 J C - REMARKS Z
0
GEOTECH REPORT
BY: m
STRUCTURAL DESIGN
BY:
VALUATION
$ '
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee'
5
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. Engf. Review.
to PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
IL PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection ✓
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
w 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire ,RevIBW r` ' Plan Chk, Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection1 �1 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
oDEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due t'IJ
= 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
THE OWNER. (.AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is hot a perrmt until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Foes are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATIO SURANCE AND RCW 18:27.
OFFICIALS SIGNATURE DATE
SIGNAT E (OWNER ORA ENT ' DATE SIGNED (425)
.a 771m0220 RELEA DAT
ATTENTION EXT. 1333
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
j q I
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL. OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 I IBC110 1 IRC110. PINK L F E YELLOW •INSPECTOR
PINK - N R •GOLD •ASSESSOR .
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