20051109.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWN R NAME/NAAtE OF BUSINESS
MAILING ADDRESS
OI ZIP TELEPHONE
iL611- ZLa 770�b�
NAME
ADDRESS
TELEPHONE
NAME CBL#
6 CN15
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CITY ZIP TELEPHONE
STATE LICENSE NUMBER EXPIRATION DATE
PROPERTYTAXr
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❑
NEW
ADDITION
REMODEL
❑
REPAIR
❑
DEMOLISH
❑GARAGE
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CARPORT
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(TYPE OF USE, B
NUMBER —
OF
STORIES
DESCRIBE WORK TO BE
ARCEL NO.
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PERMIT EXPIRES JO/ I
PERMIT r� ��/���y
NUMBER
JOB
ADDRESS SUITE/APTn
PLAT NAME/SUBDIVISION NO, LOT NO, LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPAppro•na
RW NMI Required
EXISTING PROPOSED Street Use Perm•t Required
-...._..._.-__ -. Inspectzn Required
Sidi Requited
REQUIRED DEDICATION FT _ _ Undergrour.a
Wu.oa reau,ren
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES ❑ NO ❑
REMARKS
C%VNERICONTRACTOR RESPONSIBLErFOR EROSION CONTROUDRAINAGE
193
LI On fuel -burning appliances
BY FIrREV of
REt'i➢ MYp�
RESIDENTIAL An, PLUMBING / MECH
❑ COMMERCIALCOMPLIANCE OR
❑ MIXED USE ❑ CHANGE OF USE
❑ MULTIFAMILY ❑ SIGN
❑ GRADING CYDS FENCE
( X FT.)
❑ TANK ❑ OTHER
❑RETAINING WALL❑ FIRE SPRINKLER
ROCKERY FIRE ALARM
R ACTIVITY) EXPLAIN:
NUMBER OF j
DWELLING /
UNITS
CAM
❑ WAIVER
❑ STUDY
LOT CC
ALLOWED
PARKING
REO'D I PRO'
REMARKS
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AUb# INSPECTION SEPA
REQ'D COMPLETED EXEMPT
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SIGN AREA HEIGHT
ALLOWED PROPOSED ALLOWED PROPOSED
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SPECIAL INSPECTION CONSULTANT OCCUPANT
REQUIRED LOAD
REMARKS -piyS PIPE TEST MUST BE
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BY- AFFID.
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$VALUATION "
Description FEE Description FEE
HgAT 5OUR LOT SLOPE°o VESTED -GATE Plan Check State Surcharge
PLfy CHEEC7 K NO: Building Permit City Surcharge s
Plumbing "' Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC Mechanical
R DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
t SEPARATE PERMISSION, Grading
ul PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Engr. Review Recording Fee
°• PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection Plan Chk. Deposit
N 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
W IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review Receipt #
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 Fire Inspection Total Amt. Due
d DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
2 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' Landscape Insp. Receipt #
I I I ZEI
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-
TION; Building Official or his/her Deputy and Fees are paid. and
AND IN DOIN AU THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION
IN VIOLATIO THE LABO E Of T E STATE OF WASHINGTON RELATING TO receipt is Howled din space provided
WORKME COMPENSATION• NSUR NCE D FICIN 18:27%. ( O FI AL IGNA U E DATE
SIGN URE(OWNER GENTJ: DATE SIGNED ���� V
771 _0220
REASEb GYI DAT
ATTEN ON EXT. 1333
IT IS UNL WFU USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINA I CTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OCCUPANCY HAS BEEN GRANTED, UBC109 I IBC110 It IRC110, ORIGINAL • FILE YELLOW • INSPECTOR
PINK -OWNER GOLD • ASSESSOR
6105 PRESS HARD = YOU ARE MAKING 4 COPIES
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