20050980.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
PERMIT EXPIRES
PERMIT
NUMBER
JOB
ADDRESS,
SUITE/APT#
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-Ta(t-(_� 1. ,, ( 6, -_I,
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
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MAILINGADDREP$
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LID FEE S
TESCP Approved E3
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required CI
EXISTING PROPOSED
Street Use Permit Requited [3
Inspection Required 11
Sidewalk Required E3
CITY ZIP
TELEPHONE
L/
01Y
REQUIRED DEDICATION FT
Underground [3
Wifin 4 required E3
NAME
IVIETER SIZE
LINE SIZE
NO. OF FIXTURES
. REQUIRED
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YESO NO13 z
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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LATY 11 ZIP
ITELEPHONE
ADDRESS
TELEPHONE
STATE
PROPERTY TAX ACCOUNT PARCEL NO.
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El
NEW
VRESIDENTIAL
ADDITION
COMMERCIAL
MIXED USE
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
1:1
DEMOLISH
El TANK
GARAGE
RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE. BlJaWSSS OR ACTIVITY) EXPLAIN
CBL#
RATION DATE CHECKED BY
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XBING MECH
COMPLIANCE OR
CHANGE OF USE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE L1j
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VARIANCE OR CU SHORELINEORADBI I INSPECTION SEPA '
REO'D 01 COMPLETED EXEMPT
13YES 13N I
CA# ZONE SIGN AREA HEIGHT
WAIVER 13 ALLOWED , PROPOSED ALLOWED , PROPOSED
STUDY 13 1 1
LOT COVERAGE REQUIRED SETBACKS (rT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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PARKING LOT AREA I PLANNING REVIEWED BY DATE
SIGN REQ'D PROVIDED
FENCE I
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OTHER
FIRE SPRINKLER
FIRE ALARM
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TYPE OF Solowucl
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NUMBER
OF
STORIES
NUMBER OF
DWELLING
UNITS
SPE 'ECTION
REQUIRED 13YES
DESCRIBE WORK TO BE DONE
REMARKS
GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description
Plan Check
HEAT SOURCE
LOT SLOPF��
VESTED DATE
Building Permit
PLAN CHECK NO: '2-
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS,. MARQUEES, ETC,) WILL REQUIRE
SEPARATE PERMISSION.
Grading
Engr. Review
PERMIT APPLICATION, SEE ECDC 119.00.005(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
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
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."
A
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT: AND T14AT I AM THE OWNER, OR THE DULY AUTHORIZED AGENTOF
OCCUR
GROUP
CONSULTANT
OCCUPANT
LOAD
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
THE OWNER. I AGREE 30 COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
V L FOR INSPECTION
EITN, VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
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W W M
ORKMEN;AX.O�TSATION INSURANCE AND RCW 118:27.
OR OSV
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IGNATURkQ!N.EJRR AGENT):, DATE SIGNED (4,25)
771 0220
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.
10104 PRESS HARD - YOU ARE MAKING 4 COPI
Plan Chk. Deposit
Receipt #
Total Amt. Due
A
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APPLICATION APPROVAL
This application is not a pormil until signed by the
Building Official or his1hor Dopuly and Fees arc paid and
receipt is acknowledged in space provided
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