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•� DATE RECEIVED
- C PERMIT EXPIRES D
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CITY OF EDMONDS Nu BER 5
CONSTRUCTION PERMIT APPLICATION Ao
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OWNER NAMEINAME OF BUSINESS J , '�*• 4 / /
So C/I11 C V✓ I S•�J � V .r � PY)T{ r PLAT NAMEISUBDIVISION NO. LOT NO. LID NO.
IY MAILING ADDRESS LID FEE S
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Porm,PRen�red Cl
V CJ Street Use Permit Required 0
CITY ZIP TELEPHONE EXISTING _ PROPOSED ___ Inspection Reqwred O
J Sidewalk Required
V r% LJ'z U Y �.7 - '7 7y - v ��� REQUIRED DEDICATION FT underground O
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NAME METER SIZE LINE SIZE NO. OF FIXTURES I PRV REQUIRED
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE o
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NAME CBL#
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ICITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE K
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c PROPERTY TAX ACCOUNT PARCEL NO.
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NEW
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ADDITION
REMODEL
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REPAIR
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DEMOLISH
❑GARAGE
CARPORT
❑ RESIDENTIAL ❑ PLUMBING I MECH
COMMERCIAL COMPLIANCE OR
❑ MIXED USE ❑ CHANGE OF USE
❑ MULTIFAMILY ❑ SIGN
❑ GRADING❑ FENCE.
CYDS ( X
❑ TANK ❑ OTHER
❑RETAINING WALL-ii1MIRl�R�
ROCKERY FIRE ALARM
ENGINEERING REVIEWED BY
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ED BY DATE w
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E OR CU SHORELINE OR ADB# INSPECTION SEPA
REQ'D COMPLETED EXEMPT
I7 YES 0 NO
ZONE SIGN AREA HEIGHT
ALLOWED PROPOSED ALLOWED PROPOSED
OVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
PROPOSED FRONT SIDE REAR FRONT. UR SIDE REAR l7
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ING LOTAREA PLANNING REVIEWED BY DATE g
ROVIDED
FT.) I REMARKS
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
TYPE OF COTRAUCCTTIION C DF OCCUPANT
SSI �Ur^ Ce rv� /(t i9yY1 GROUP
NUMBER NUMBER OF
OF DWELLING jam] SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS I — LOAD
DESCRIBE WORK TO BE DONE REQUIRED O YES
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BY:
VALUATION
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY..ANY CONSTRUCTION ON THE PUBIC Gradin
E DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
J SEPARATE PERMISSION,
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
L 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
Aj IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection IReceipt
eipt #
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. DUB
_ NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION'$
Recording. Fee #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION A PROVAL
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 Building Official or his/her Deputy: and Foes are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATIrWSVANCE AND RCW 15:27.
OFFICIALS SIG5,ATURE DAT[
SIGNATUR (OWNER OR GENT): DATE SIGNED (425)
7 !x 1 m022QRE AS (• DATE
ATTENTION EXT. 1333 f �� .►-�
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 -INSPECT R.
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC110 I IRC110, PINK -OWNER.• GOLD - ASSESSOR
10/04 PRESS HARD = YOU ARE MAKING 4 COPIES
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