20050939 (2).pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PROPERTY TAX ACCOUNT PARCEL NO.
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PLAT NA/dE/SUBDIVISION NO, LOT 140. LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPAPProvetl I'
RW Permit Required 13
EXISTING PROPOSED Street use Pennd Required O
-- Inspection Required E3
Sidewalk Requved 13
REQUIRED DEDICATIONpT underground 17
-- — Wifina ry wrod O
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NO E3 z
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REMARKS w
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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ENGINEERING REVIEWED BY DATE
F-11 1E MARSHAL
FIRE REVIEWED BY MOO ` iw TE
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REQ'D COMPLETED I EXEMPT
O YES 13NO
CA# ZONE SIGN AREA HEIGHT
WAIVER O ALLOWED- PROPOSED ALLOWED PROPOSED
STUDY a
❑ NEW RESIDENTIAL❑ PLUMBING / MECH LOT COVERAGE I REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIR SIDE REAR
COMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑ USE z
❑ MIXED USE CHANGE OF z
❑ REMODEL❑ MULTIFAMILY ❑ SIGN REQ'D ARPIROVIDED LOT AREA PLANNING REVIEWED BY DATE g
❑ REPAIR ❑ GRADING ❑ FENCE
CYDS ( X FT.) REMARKS
❑ DEMOLISH TANK ❑ OTHER
z ❑GARAGE RETAINING FIRE
CARPORT ❑ ROCKERY WALL ❑ FIREALARM SPRINKLER
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(TYPE O 11SE, BUSINESS R AC IVITY) EXPLAIN:
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GROUP
G NUMBER NUMBER OF
m OFDWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
O STORIES UNITS LOAD
DESCRIBE WORK TO BE DONE REQUIRED YES
REMARKS
GEOTECH REPORT
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P01n*1At'x- Description FEE Description FEE
Plan Check Stale Surcharge
HEAT SOURCE LOT SLOPE%, VESTED DATE
Building Permit 16 City Surcharge
PLAN CHECK NO: Plumbing Base Fee
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO MBChanICBI
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC
g DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
I= SEPARATE PERMISSION.
w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Engr. ROVIBW
IL PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review 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 Inspection Receipt #
ALI. 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 1 HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPR VAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER, 1 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is not a permit 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 Fees 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 COMPENSATION414AURANCE AND RCW 18:27.
OFFICIALS SIGNATURE DATE
SI E It ER)' DATE SI NED (425)
F
771 =0220 RELIfASED BY DATE
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, UBC109 I IBC110 / IRC110. PINK -OWNER •GOLD •ASSESSOR
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