20050979.pdfDATE RECEIVED
FPERMIT EXPIRES
CITY OF EDMONDS
PIERMIT
NUMBER ) 6�_ - C) �2
JOB
SUITEIAPT#
CONSTRUCTION PERMIT APPLICATION
ADDRESS
OWNER NAMEINAME OF BUSINESS
PLAT NAMEISUBDIVI SION NO.
LOT NO.
LID NO.
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LID FEE S
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MAILING ADDRESS
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW permit Requirod
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EXISTING PROPOSED
Street Use Pernut Required
inspection Required
Sidewalk Requited
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CITY ZIP
TELEPHONE
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REQUIRED DEDICATION FT
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METER SIZE LINE SIZE IXTURES
PRV REQUIRED
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YES 13 NOM
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ADDRESS
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY REQ'D COMPLET
113YES 13NOI
CA# ZONE SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO. VER'bir
WAI ALLOWED , PROPOSED ALLOWED , PROPOSED
STUDY 13
POSED SETBACKS (FT.)
NEW RESIDENTIAL PLUMBING MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PRO
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIRSIDE REAR
COMMERCIAL COMPLIANCE OR
ADDITION z
MIXED USE CHANGE OF USE z
PARKIN LOTAREA PLANNING REVIEWED BY DATE
REMODEL G
MULTIFAMILY SIGN REO'D PROVIDED
REPAIR GRADING CYDS FENCE . I . I
( X. FT.) REMARKS
/PA'a OTHER
DEMOLISH TANK
RETAINING WALL FIRE SPRINKLER
CARPORT El ROCKERY FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY LAIN: TY . N9 OF.IC 12 ON OCCUPANT
NUMBER NUMBER OF UMV n GRO
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS rl I [LOAD
DESCRIBE WORK TO BE DONE
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REQUIRED YES
REMARKS
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VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
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City Surcharge
PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
Grading
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DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
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SEPARATE PERMISSION.
Engr. Review
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PERMIT APPLICATION: SEE ECDC 19.00,005(A)(5)
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
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IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
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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
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Total Amt. Due
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176;
C NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
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Recording Fee
Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMAT16N
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-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
CALL
Building Official or his/her Deputy: and Fees me 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 Spo� ION INSURANCE AND RCW 18:27.
OFFICIALS SIGNATURE DATE
SIGNATUR, INER RAGENT):
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DATE SIGNED
(425)
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771-0,220
DA-511f
BY
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. UBC1091 IBC110 I IRC110.
P114K -OWNER GOLD - ASSESSOR
10/04 PRESS HARD - YOU ARE MAKING 4
COPIES
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