20051108.pdfi DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER ME/NAfdE F BUSINESS
MAILING ADDRESS
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NAME
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PERMIT
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STATE LICENSE NUMBER EXPIRATION DATE CHE KE BY FIRE REVIEWED BY
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-' PROPERTY TAX ACCOUNT PARCEL NO. VARIANCE OR CU SH"if
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❑ NEW RESIDENTIAL ❑ PLUMBING / MECH [] WAIVER •�'�Ci
❑ COMMERCIAL COMPLIANCE OR ❑STUDY
❑ ADDITION ❑ CHANGE OF USE LOT COVERAGE REQUIRED
❑ MIXED USE ALLOWED PROPOSED FRONT
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❑ REMODEL ❑ MULTIFAMILY ❑ SIGN S'UAN
❑ REPAIR ❑ GRADING❑ FENCE
CYDS ( X FT.) 'PARKING 4i
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HEIGHT
ALLOWED PROPOSED PROPOSED
KS (FT.) PROPOSED SETBACKS (FT.)
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OTHER REO D PROVIDEIb` WJV14tC'
❑ DEMOLISH ❑ TANK ❑ I �5;`!i` prr�j2S ••"-�
_ ❑GARAGE RETAINING WALL FIRE SPRINKLER REMARKS
CARPORT ❑ ROCKERY FIREALARM
n(TYPE OF USE, BUSINESS OR CTIVITY) EXP IN;
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w NUMBER NUMBER OF
OF j DWELLING
p STORIES ` UNITS TYP N TRUCTION CO E [OCCUPAN•
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DESCRIBE WORK TO BE DONE �JIJ V
SPECIAL INSPECTION CONSULTANT OCCUPANT
REQUIRED 13YES LOAD
REMARKS c
GEOTECH REPORT
BY: r
STRUCTURAL DESIGN
6Y•
VALUATION
.�722tis?�'t"l f3IV $
�� Description FEE Description FEE
HEAT SOU CE LOT SLOPE°a , VESTED DATE Plan Check State Surcharge
PLAN CHECK N0: Building Permit City Surcharge
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
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
t SEPARATE PERMISSION, Grading
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a Engr. RBVIBW Recording Fee
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
J IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review Receipt #
i EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY Fire Inspection Total Amt. Due .�
FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
In
O DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE ,..r
i 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 application is not a permit until signed by the
THE OWNER, I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• Building Official r hismor Deputy and Fees are pad. and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION r t knowledged in space pr vided
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATIO RANCE AND RCW 19:27. (425) OFF I S SI TU 0 'E
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SIGNATURE INNER dq AGENT): DATE SIGNED l LJ
12 �0 S 771 -0220 RELEASED Y D F..
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ATTENTION
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL X ( 3/ _
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- / _ 1p ORIGINAL - FILE YELLOW - INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 / IBC110 / IRC110. PINK -OWNER GOLD - ASSESSOR
6105 PRESS HARD - YOU ARE MAKING 4 COPIES
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