20051095.pdff DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY, Zip TELEPHONE
NAME
ADDRE
NAME CBL#
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ADDRESS
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CITY ZIP TE IONE
S&c4m-e, C1 9 11 T361t -1 AS 155 f _:�>
STATE LICENSE NUMBER EXPIRATION DATE CHECKED 13Y
PROPERTY TAX ACCOUNT PARCEL NO.
1:1
NEW
RESIDENTIAL
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ADDITION
COMMERCIAL
MIXED USE
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REPAIR
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GRADING CYDS
DEMOLISH
TANK
GARAGE
RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE. BUSINES ORACTIVI I
AL 'S
PLUMBING (9)
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
( � X FT.)
OTHER
FIRE SPRINKLER
FIREALARM
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LPERMIT EXPIRES
PERMIT loq,45
NUMBER
JOB
ADDRESS LIT PTI
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PLAT NAME/SUBDIVISION NO,
LID NO�
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApproved E3
EXISTING PROPOSED
RW Permit Required 0
Street Use Pernut Requited 13
inspection Requilod 11
Sidewalk Requited 0
Undortiround E3
REQUIRED DEDICATION FT
Wifing Mquitud E3
METER SIZE LINE SIZE PRV REQUIRED
YESO NOO
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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VARIANCE OR CU SHORELINE OR ADB# F_3�
REO'D COMPLETED IrEXEMPT
1113 YES [3 NO
CA# ZONE SIGN AREA LHEIGHT
WAIVER 13 ALLOWED I PROPOSED LOViED , PROPOSED
STUDY [3 1
LOT COVERAGE RtEQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
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ALLOWED VKUtUZ�t:1LIF - I—— I -.--
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NUMBER
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NUMBER OF
DWELLING
UNITS
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SPECIAL 114SPECTION
REQUIF
CONSULTANT
DESCRIBE WORK TO BE DONE
REMARKS
01-/ 4V
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GEOTECH REPORT
BY:
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STRUCTURAL DESIGN
BY:
VALUATION
$
Y) OR
Description
FEE
Plan Check
HEAT SOYRCE
a-, 0 1
LOTSLOPE
VESTED DATE
Building Permit
PLAN CHECK NO:
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Grading
Engr. Review
rx
LU
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
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*APPLICANT. 0 N BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
Fire Review
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2
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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
Fire Inspection
Landscapeinsp.
0
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,
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-
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
CALL
FOR INSPECTION
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
-OFF
(425)
771-11`11271711
nd.
I
SIGNATURE (OWNER OR A6&Iftj
A A J a41-111-ij
DATE SIGNED
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 / IRC110.
OCCUPANT
GROUP
OCCUPANT
LOAD
Description FEE
State Surcharge
I City Surcharge C)40
Base Fee 30
Plan Chk. Deposit
Receipt #
Total Amt. Due
zy S
1 Receipt �_i �
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or hisiner Deputy: and Fees are paid, and
Welill is acknowledged in space provided.
IC21ASSIGN UR,E j
DAT
PASEPNY DAT E
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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