20051105.pdfy DATE RECEIVED /
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMErNAME OF BUSINESS
MAILING ADDRESS
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CIN ZIP TELEPHONE
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NAME
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PERMIT EXPIRES
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PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TLGCP Aparosooa ❑
R\Y Permr. Requ.rea ❑
Street Use Permit Reciaea ❑
EXISTING _. _.....-_.---_ PROPOSED -----_--__._--..----- —. Inspeeeon Required ❑
Sidev.al. Required ❑
Underground 13REQUIRED DEDICATIOI _ — FT ___
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METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES in NOM
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REMARKS z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE ¢
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RECYCLE REVIEWED BY DATE
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¢ PUBLIC WORKS REVIEWED BY DATE
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EXPIRATION DATE „C CKED Y FIRE REVIEWED BY DATE w¢
STATE LICENS.E/NUMBER
%'L '� VARIANCE OR cu OR ADB# INS EP CTIOvN ( SEPA
PROPERTY TAX ACCOUNT PARCEL NO. REO'D COMPLETED EXEMPT
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921 CA# ZONE SIGN AREA HEIGHT
RESIDENTIAL ❑ PLUMBING! MECH ❑ WAIVER ALLOWED PROPOSED ALLOWED PROPOSED
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NEW
COMMERCIAL COMPLIANCE OR STUDY
❑ ADDITION' "t° ❑ CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
13 MIXED USE ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ REMODEL MULTIFAMILY ❑ SIGN
GRADING FENCE
❑ REPAIR ❑ CYDS ❑ ( X FT.) PARKING LOTAREA PLANNING REVIEWED BY DATE
REO'D PROVIDED
❑ DEMOLISH ❑ TANK OTjjE
GARAGE ❑ RETAINING WALL FIRE
SPRINKLER REMARKS
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
N NUMBER OF
W NUMBER
O OF DWELLING TY EQFCONyiT�UCTION CODE OCCUPANT.
p STORIES UNITS - [.i GROUP
DESCRIBE WORK TO BE DONE
T SPECIA INSPECTI CONSULTANT LOAD
PANT
REQUIRED O YES
REMARKS
GEO'iECH REPORT
BY:
STRUCTURAL DESIGN
BY,
VALUATION
$
Description FEE Description FEE
HEAT SOURCE LOT SLOPE
VESTED DATE Plan Check State Surcharge
Cit Surcharge
Building Permit � y 9
PLAN CHECK N0:
Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
9 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
t SEPARATE PERMISSION.
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Engr. Review Recording Fee
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection Plan Chk. Deposit
w •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Receipt N
Us IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review p
N ITS OFFICIALS EMPLOYEES AND AGENTS FROM ANY AND
e EDMONDS, WASHINGTO
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARI SING DIRECTLY OR INDIRECTLY Fire Inspection -- Total Amt. Due .
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 ReC21pI #
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' Landscape Insp.
APPLICATION APPROVAL
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION CALL This application is not a permit until signed by the
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF Building official or Misner Deputy: and Fees are paid. and
THE OWNER, I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• off receipt iis acknowledged to space provided
INOVIOLATIN DOING THE WORK AUTHORIZED ION OF THE LABOR CODE OF THE HSTATE OFOWASHI WPERSON ASHINGTON RELATING TO ILL BE EMPLOYEDFOR INSPECTION
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. (425) OFFICIALS SIGNATURE DATE
SICWNER O A DATE SIGNED 771 =0220
// 9 oS' o DATE
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ATTENTION
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 -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 / IBC110/ IRC110. PINK -OWNER GOLD • ASSESSOR
6/05 PRESS HARD = YOU ARE MAKING 4 COPIES
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