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PERMIT EXPIRES l v
CITY OF EDMONDS Nu BER GC1
CONSTRUCTION PERMIT APPLICATION JOB SUITEIAPT#
ADDRESS •')
OWNER NAMEINAME OF BUSINESS G/`
PLAT NAMEISUBDIVISION NO. LOT NO. LID NOwy.
W MAILING ADDRESS LID FEE 5
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/9�), / �V PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW CP PermitReqApproved ❑
`� �• I Gl �- G. �ir� �l/ RW Permit Required R ❑
Street Use PermA Required ❑
CITY ' ZIPTELEPom required
EXISTING PROPOSED Inspection Required ❑ E3Sidewalk Required
REQUIRED DEDICATION FT Underground O
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NAME METER SIZE LINE SIZE NO. OF FIXTURES, PRV REQUIRED
YES13 NOD z
UC
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I_ ADDRESS REMARKS w
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u OWNER/CONTRACTOR REt4RgN61B FSR EROSIUN 90 _7R LID I 4E
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CITY ZIP TELEPHONE t 14.4f INSDECIOR
NAME CBL#
ENGINEERING REVIEWED BY GATE
rY ADDRESS
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FIRE REVIEWED BY DATE W
o CI Y ZIP TELEPHONE
PA
STATE LICENSE NUMBER EXPIRATION DATE C BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION ED I
� � REQ'D COMPLETED EXEMPT
YES � NO
CA# ZONE SIGN AREA HEIGHT
a PROPERTY TAX ACCOUNT PARCEL NO.
W J �--� WAIVER O _ ALLOWED PROPOSED ALLOWED PROPOSED
STUDY �
❑ NEW RESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR 0
El COMPLIANCE COMPLIANCE OR _
❑ ADDITION ❑ CHANGE OF USE Z
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE a
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
GRADING FENCE
❑ REPAIR ❑ CYDS ❑ ( X FT.) REMARKS
❑ DEMOLISH ElTANK ❑ OTHER
❑ GARAGE CARPORT ❑ ROCKENING RY WALL FIRE ❑ FIRER ARM LER
W*
NUMBER NUMBER OF t
OF DWELLING SP CIAL INSPECTION CONSULTANT OCCUPANT
p STORIES .UNITS LOAD
-r REQUIRED YES
DESCRIBE WORK TO BE DONE
REMARKS z
0
C GEOTECH REPORT all
BY:
�� /� V Cnf� •/(J / S STRUCTURAL DESIGN
T_ BY:
' . l Ame VALUATION
Description FEE Description FEE
/16 Plan Check State Surcharge
HE O RC SLOP o VESTED DATE
C' Building Permit City Surcharge
PLA CHECK NO:Plumbing Base Fee
276
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO MBChanICBI 1
t- 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
Lu PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. Inspection
rn *APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
LU IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
C 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 #
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. 1 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL Building Official or hislhor Deputy: and Fees aro paid, and
TION; AND IN DOING TH WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt i. acknowle ged in space provided.
IN VIOLATION OF TH L R CODE OF THE STATE OF WASHINGTON RELATING TO p
WORKMEN'S COMPEN N NCE AND RCW 18:27, FFI S N T RE DAT
WSIGNARE(OWNER RAGE T):/%/DATE SIGNED(425)`/l(/771 0220 RELE ' E B CAT
NTION 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. UBC109 / IBC110 / IRC110, PINK -OWNER GOLD - ASSESSOR
10/04 PRESS HARD w YOU ARE -MAKING 4 COPIES
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