20050976.pdf0
DATE RECEIVED
PERMIT EXPIRES
CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION
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OWNER NAME/NAME OF BUSINESS
PLAT NAMEISUBDIVISION NO. LOT NO. LID NO.
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MAILING ADDRESS ^•J ,l LID FEE 5
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JP '7 rl ` PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required ❑
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Street Use Permit Requited Cl
CITY ZIP TELEPHONE EXISTING _ PROPOSED Inspection Required ❑
Sidowalk Required ❑
REQUIRED DEDICATION FT UndergroundWtnnq eit [3
NAMEMETER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE z
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FIRE REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTIONREQ'D SEPA
COMPLETED EXEMPT
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PROPERTY TAX
�ACCOUNT PARCEL NO. WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED
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❑ NEW ❑ RESIDENTIAL ❑ PLUMBING I MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
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❑ COMMERCIAL COMPLIANCE OR
❑ ADDITION ❑ CHANGE OF USE Z
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL LM>0SMU
LTIFAMILY ❑ SIGN REO'D PROVIDED
GRADING❑ FENCE
REPAIR 13CYDS ( X, FT.) REMARKS
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Z ❑GARAGE RETAINING FIRE S
CARPORT ❑ ROCKERY WALL ❑ FIREALARM RINKLER
CL (TYPE OF USE, BI G ESS OR ACTIVITY?PLAIN: TYPE OFON TRUCTION CODE OCCUPANT
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GROUP
LU NUMBER NUMBS OF
0 OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
MUNITS LOAD
STORIES
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D CRIBS ORK TO BE DONE
REMARKS i
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GEOTECH REPORT m
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VALUATION
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Description FEE Description FEE
Plan Check Slate Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge I
PLAN CHECK NO: j Plumbing Base Fee
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO MOChanIC81
t- BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE Grading
C 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 Engr. Inspection
Fire Review Plan Chk. Deposit
m `APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
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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 # L
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. DUO
0 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. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL Budding Official or hislhor Deputy and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE L CODE OF DJE_S•TATE OF WASHINGTON RELATING TO FOR INSPECTION roto pl is arknowledgud in spaco provided
WORKMEN'S COMPENS I "E` NDW 16:27, FFI ALS SIGN it IE TE
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IGNATURE(O�IJ O GENT DATE SIGNED (42S) - 7 --
013 771-0220 RE : SED �Y DATE
A,: ENTION EXT. 1333
fT IS UN LA FOIL TO'GSE OR OCCU A BUILDING OR STRUCTURE UNTIL.1000
A FINAL SP,,E&ION HAS BEEN MADE AND APPROVAL OR A CERTI- of IGINAL • FaE •YELLOW -INSPECTOR
FICATE CCUPANCY HAS BEEN GRANTED. UBC1091 IBC110 I IRC110, INK • OWNE • GOLD • ASSESSOR
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