20050970A.pdfFDATE RECEIVEE�
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
CITY ZIP TELEPHONE
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ADDRESS
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CITY ZIP rELEPHONE
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STATE LICENSE NUMBER _�.-EXPIRATION DATE CHECKEDB
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PF49 ERTY TAX ACCQUNT
PARCE�L NO
NEW
NrRESIDENTIAL
ADDITION
COMMERCIAL
MIXED USE
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
GARAGE
RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN
NUMBER
NUMBER OF
OF
DWELLING
STORIES
UNITS
DESCRIBE WORK TO BE DONE
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PERMIT EXPIRES
VERMIT
NUMBER.
JOB
SUITEIAPT#
ADDRESS
PLAT NAMEISUBDIVISION NO.
LOT NO
I
LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApptovoci
13
13
RIW Permit Required
Street use Permit Required
13
EXISTING PROPOSED
Inspection Required
E3
SKIdwalk Required
CI
REQUIRED DEDICATION FT
underground
C3
E3
Wifina required
METER SIZE
LINE SIZE
NO. OF FIMU`RES__
PRV REQUIRED
YES 13 NOO
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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AFHDAVff�j' 'A'S'Flid If. NOT
ENGINEERING REVIEWED BY B� j�
DATE
FIRE REVIEWED BY
DATE
VARIANCE OR CU SHORELINE OR ADB# INSPECTION01 SEPA
,REO'D COMPLETED I EXEMPT
113YES 1-1 N
CA# ZONE SIGN AREA HEIGH
WAIVER 13 ALLOW ED , PROPOSED ALLOWED PROPOSED
STUDY 13
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LOT COVERAGE I REQUIRED SETBACKS (FT.) PROPOSIzU b1z I UAUKz, %r 1 -11
PLUMBING I MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT L/RSIDE REAR
COMPLIANCE OR z
CHANGE OF USE L
PARKING EA PLANNING REVIEWED BY DATE
L_j SIGN REO 49A
EFENCE
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FIRE SPRINKLER
FIRE ALARM t
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TYPE
SPECIA1 INSPECTION
REQUIRED 13YES
REMARKS
'cal Permit Irm 1
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6
CONSULTANT
16c), M 2_ni-4
$
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Description
Plan Check
HEAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
PL(jCHECK NO:
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
Engr. Review
SEPARATE PERMISSION.
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
---
Fire Inspection
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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
NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
11111111PIIIIIIII
Recording Fee
CALL
FOR INSPECTION
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WORK AUTHO� THEREBY, NO PERSON WILL BE EMPLOYED
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IN VIOLATION OF THE LABOR COI)E 0 TT"E STATE OF WASHINGTON RELATING TO
WORKMEN'S S��ENSATION INSU ANP RCW 18:27.
/KANCE
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SIGNATURI(16)49EPOR�,13 T):'
DATE SIGNED
017'-4
FEE
OCCUPANT
GROUP
OCCUPANT
LOAD
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couxlectors required
S S 1 n g
Description FEE
State Surcharge
City Surcharge
.cf
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due L)
Receipt # 5
APPLICATION APPROVAL
This application is not a pernnit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
ICIAOIS SIGNATURE 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-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 I IRC110.
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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