20051023.pdfDATE RECEIVED
PERMIT EXPIRES J` --O
CITY OF EDMONDS
PERMIT
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CONSTRUCTION PERMIT APPLICATION JOB SUITEIAPT#
ADDRESS 7
OWNER NAME/NAME OF BUSINESS
Lcn ) PLAT NAMEISUBDIVISION NO. LOT NO. LID NO.
MAILING ADDRESS C /l/ CJ LID FEE S
N/ FT— a PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Req d ❑
l7 1 ���'�"��� RW Permit Required ❑
CITYStreet Use Permit Requited 13ZIP TELEPHONE EXISTING PROPOSED inspection Required ❑
mrW OUndergrauu^ �yy.rmnU�REQUIRED DEDCATION
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NAME METER SIZE LINE SIZE NO.tOF F,IxTURES:1 ' 4 �;ISYRV REOUIREO
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STATE LICENSE NUMBER EXPIRATION DATE C ECK Y ARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REQ'D COMPLETED I EXEMPT
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PROPERTY
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�X jACCOUN7 PARCEL NO. WAIVER O ALLOWED PROPOSED ALLOWED PROPOSED j
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❑ NEW RESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
IIIJIIX ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ COMMERCIAL COMPLIANCE OR ?
❑ ADDITION ❑ MIXED USE ❑ CHANGE OF USE z
❑ REMODEL El MULTIFAMILY ❑ SIGN REQ'DARPIROVIDED LOTAREA PLANNING REVIEWED BY DATE g
❑❑ GRADING ❑ FENCE X FT.) REMARKS
REPAIR CYDS
❑ DEMOLISH ❑ TANK ❑ OTHER
❑ GARAGE RETAINING CARPORT El ROCKERY WALL ❑ FIRE ALARM FIRE LER
(TYPE OF USE, BUSINESSORACT�iY) E PLAIN:
IT TECO CONS DIN C %; OCCUPA;LOAD
GROUP
NUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS I
I REQUIRED L YES
DESCRIBE WORK TO BE DONE
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Description
Plan Check
HEAT rS0 RCE LOT SLOPE% VESTED DATE
%V Building Permit
PLAN CHECK NO: Plumbing
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical
I= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
i DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE Grading
i SEPARATE PERMISSION, Er1gG RBVIBW
It W PERMIT APPLICATION: SEE ECDC 19.00,005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
BACK OF PINK PERMIT FOR MORE INFORMATION
•APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review
W IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
i EDMONOS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection
ot ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
T 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.
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
Recording Fee
1 HEREBY ACKNOWLEDGE THAT 1 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• CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LAGO&SdDOE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S COMPEN9A CE AND RCW 16:27.
SIGNAT OWNER R AG NT DATE SIGNED (425)
771-0220
FEE Description
State Surcharge
�l City Surcharge
V \ Base Fee
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Due
,
Receipt #
APPLICATION APPROVAL
This application is not a ponnit until signed by the
Building Olficial or hislhor Deputy* and Foes are paid, and
rucoiflits acknowle Iged in space provided.
FICIAL
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URE uDATE�
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.C. +EU iY 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, UBC109I IBC110If IRC110,
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL . FILE YELLOW • INSPECIOR
PINK • OWNER GOLD • ASSESSOR
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