20050907 (2).pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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NAME/SUBDIVISION NO. LOT NO LID10,
LID FEE 5
IC RIGHT OF WAY PER OFFICIAL STREET MAP RW PoritReqApproved 0
. RW Pormd Required �
Street Use Pennd Required E3
ING PROPOSED Inspochon Required O
Sidewaix' Required O
IRED DEDICATION FT Underground O
Min required 17
TER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YESE3 NOE3 z
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W
ARKS w
RESPONSIBLE FOR EROSION CONTROLIDRAINAGE F5
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NAME CBL#
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STATE LICENSE NUMBER EXPIRATI N D TE Y VA ANCE OR CU L SHORE E OR ADB# INSPECTION SEPA
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REQ'D COMPLETED EXEMPTOY
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CA# ZONE SIGN AREA HEIGHT
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WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED
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❑ NEW 0 RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR t7
COMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑ CHANGE OF USE Z
❑ MIXED USE PARKING LOTAREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑ REPAIR ❑ GRADING CYDS ❑ FENCE X FT.) REMARKS
❑ DEMOLISH ❑ TANK
GARAGE RETAINING WALL FIRE SPRINKLER
Z ❑ CARPORT ❑ ROCKERY ❑ FIREALARM
O (TYPE OF USE, BUSINESS R ACTIVITY EXPLAIN:
! u TYPE OF CONST UCTION /C�OD,E� OCCUPANT
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jr.'1n� L.VV GROUP
c DWELLING ,� ` SPECIAL INSPECTION CONSULTANT OCCUPANT
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O STORIES UNITS LOAD _
REQUIRED 13 YES
DESCRIBE WORK TO BE DONE
REMARKS O
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Ntt Yin it c e c GEOTECH REPORT
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WeAE ll -v l bok of" STRUCTURAL DESIGN
BY:
VALUATION
$
Description FEE Description FEE
Plan Check ��� State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE �'
Building Permit a ` City Surcharge % S
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 REQUIREIj g
Ij SEPARATE PERMISSION,
Engr. Review
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a 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
UA
IN INTEREST, AGREES TO INDEMNIFY; DEFEND AND HOLD HARMLESS THE CITY OF
2 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.'
Recording Fee Receipt #
1 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 Deputyand Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged in s:race provided.
IN VIOLATION OF THE LABOR CODE. OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27, OpIGN DATE
SIGNATU R AGENT): DAT7SI,',ED IF ` x(425)D / — f L
7 ! 1 -0220 RELEA ATE
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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 - INS ECT R
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC1091 IBC110 I IRC110• PINK -OWNER • GOLD.- ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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