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, A DATE RECEIVED 1
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS /
CITY ZIP TELEPHONE
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NAME
ADDRESS
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PERMIT �/�
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PLAT NAMEISUBDIVISION NO. LOT NO. LID NO,
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved
RW Permit Requited 17
Street use Permit Requited D
EXISTING PROPOSED _ Inspection Required D
-- Sidewalk Required D
REOUIREDDEDICATION. FT underground D
Wising required D
METER SIZE LINE SIZE 70. OF FIXTURES PRV REQUIRED
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YES 0 NoI3*
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REMARKS W
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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STA E LICENSE NUMBER � EXP RATION DATE CH D BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REV COMPLETED EXEMPT
�• d O YES NO
PROPERTY TAX ACCOUNT PARCEL NO
CAN _ ZONE SIGN AREA HEIGHT
�q• '' 0 r /7 WAIVER 13 ALLOWED PROPOSED ALLOWED PROPOSED
W U 0 STUDY 13
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
E] NEW DENTIAL ❑ PLUMBING / MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
11 COMMERCIAL COMPLIANCE OR
❑ ADDITION ❑ CHANGE OF USE
❑ MIXED USE PARKING LOTAREA PLANNING REVIEWED BY DATE
❑ REMODEL MULTIFAMILY ❑ SIGN REO'D PROVIDED
FENCE
❑ REPAIR 1:1GRADING CYDS ❑ ( ^X FT.) REMARKS
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GARAGE RETAINING WALL FIRE SPRINKLER ���' dVll4iv►� I '�
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c OF DWELLING SPECIAL INSPECTION CONSULTANT O&LOAPANT
M STORIES -UNITS 'REQUIRED O YES
DESCRI WORK TO BE DONE �^ /
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Q V N N v k F r L�K t/ev Z'T '► GEOTECH REPORT
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Q p i d sit /� o CI !'A N STRUCTURAL DESIGN40.000,
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t� / t VALUATION
Description FEE Description FEE
Plan Check State Surcharge 1�
HEAT SOURCE LOT SLOPE% VESTED DATE /
Building Permit '' City Surcharge /
PLAN CHECK NO: 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
tSEPARATE PERMISSION.
s Engr. Review
it PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
06 PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
rn 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
W IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
i EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Firo Inspection Receipt #
a 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 ` ev 50
0NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Rocording Foo 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 COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL Building Official or hislhor Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged in space provided.
IN VIOLATION OF. THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION URANCE AND RCW 18:27. OFFKalALS SIGNATURE DATE
IG TURE (OWNER O A ENT16 DATE SIGNED (425)
771w0220 w022O RELEASED BY
ATTENTION EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL -FILE YELLOW INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC1091 IBC110 I IRC1109 PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD = YOU ARE MAKING 4 COPIES
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