20051081.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF USINESS
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NUMBER
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PLAT NAMEISU BDIVI SION NO,
LOT NO.
LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TLSCP Approved
RW Permit Af-caarid
Street Use Perm-1 Required
EXISTING PROPOSED
lnsoect�on Required
Siclev,xg Required
REQUIRED DEDICA1 ION FT
Underground
Wiring requ,,en
METER SIZE
NO. OF FIXTURES
PRV REQUIRED
YESM N013
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL)DRAINAGE
NAME CBL# ENGINEERING REVIEWED BY DATE
ADDOES4 RECYCLE.REVIEWED BY DATE
CP ZIP TELEPHONE PUBLIC WORKS REVIEWED BY DATE
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STATE CENSE NUMBER EXPIKATIO DATE BY FIRE REVIEWED BY DATE
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ALLOWED PROPOSED
COMMERCIAL
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GRADING
REPAIR CYDS
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LOTCOVERAGE
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REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
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FRONT L/RSIDE REAR
PARKING
PLANNING REVIEWED BY DATE
OTHER
DEMOLISH E] TANK
RECO i PROVID
GARAGE Ei RETAINING WALL FIRE SPRI NKLER
REMARKS
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NUMBER OF
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LOAD
REMARKS
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GEOTECH REPORT
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STRUCTURAL DESIGN
BY,
VALUATION
$
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
LOT SLOPE%
F ESTED 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 PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
Grading
SEPARATE PERMISSION.
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
Engr. Review
Recording Fee
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PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
Engr. Inspection
Plan Chk. Deposit
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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"APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
Fire Review
Receipt ft
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EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
Fire Inspection
Total Amt. Due
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FROM THE ISSUANCE OF THIS PERMIT. ISSU ANCE OF THIS PERMIT SHALL NOT BE
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DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Landscape Insp.
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 CALL This appli * cation is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRLIC_ FOR INSPECTION Building Official or hisihef Deputy- and Fees are paid. and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED receipt is acknowledged in space provided
IN VIOLATION OF THE LAPOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATIO"SUPIANCE AND RCW 18:27. OFFICIALS I�JGNURE
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W N E DATE SIGNED 6 �2
SIG T RE (0, ( 8
771-0220
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ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING 08 STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL -FILE - YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 it IBC110 / IRC110. PINK -OWNER GOLD - ASSESSOR
6105 PRESS HARD - YOU ARE MAKING 4 COPIES
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