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C,5 PERMIT EXPIRES 77g'7
CITY OF EDMONDS
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CONSTRUCTION PERMIT APPLICATION ADDRESS
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OWNER NAME/NAME OF BUSINESS
WINI ;{�Al LILA PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
w MAILING ADDRESS LID FEE S
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP T[SCP Approved
13O l l v` HW Penmt Hequued ❑
CITY ZIP TELEPHONE EXISTING.. _ _ -.____. PROPOSED Street Use Peimi
inspection dwo Required ❑
L(,� ►ISA /� 1 (�iT/1 `•��l' REQUIRED DEDICATION FT underground ❑
II 1' 1/lsqtcje*dlK Required E3
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NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
U YES O NO13
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REMARKS
u OWN ICONT•RACTOR RESPONSIBLE FOR EROSION CO
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STATE LICENSE NUMBER EXPIRATION DATE CHEC FIRE REII
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a PROPERTY TAX ACCOUNT PARCEL NO.
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❑ NEW RESIDENTIAL LUMBING / MECH 13 WAIVER
COMMERCIALCOMPLIANCE OR 13 STUDY
ADDITION ❑ CHANGE OF USE LOT C
❑ MIXED USE ALLOWED
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN
❑ REPAIR ❑ GRADING CYDS ❑ FENCE
( X FT.) PARK
❑ DEMOLISH ❑ TANK ❑
OTHER REO'D I F
z ❑GARAGE RETAINING WALL FIRE SPRINKLER REMARKS
CARPORT ❑ ROCKERY ❑ FIREALARM
a(TYPE OF USE, BUSINESS ORACTIVITY) EXPLAIN:
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e NUMBER NUMBER OF
OF ' DWELLING
OSTORIES UNITS T F G,I
DESCRIBE WORK TO BE DONE
DATE
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REQ'D COMPLETED EXEMPT
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PLANNING REVIEWED BY DATE 4 I m Z
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GEOTECH REPORT m ji1
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STRUCTURAL DESIGN
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Description FEE Description FEE _
HEAT SOUqq LOT SLOPE°o VESTED DATE Plan Check State Surcharge Z
Building Permit City Surcharge /
PLAN CHECK NO: I n
Plumbing Base Fee m
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
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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 Pian Chk. Deposit
W•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 #
¢ 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 p
O DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'Landscape Insp. Receipt 0
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER THE DULY AUTHORIZED AGENT OF CALL This applications not a permit until signed by the
THE OWNER, I AGREE TO COMPLY WITH CI S TE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WO TH ED TH BY, NO PERSON WILL BE EMPLOYED FOR INSPECTION
IN VIOLATION OF BOR C OF THE TATE OF WASHINGTON RELATING TO receipt Is, nowledged In space provided
WORKMEN'S PENSATION I NCE A RCW 18;27. (425) OFF I IG UREU DAT
SIGNAT E (OWNER GEN DATE SIGNED 'fLJ
l / 1 IL
771 '0220 RELEAS 5' DAT
% EXT. 1333
A
IT IS U UL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FIN NSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI ORIGINAL . FILE • YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 / IBC110 / IRC11Of PINK - OWNER GOLD ASSESSOR
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