20051111.pdfDATE RECEIVED `
CITY OF EDMONDS.
CONSTRUCTION PERMIT APPLICATION
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NAME
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PERMIT EXPIRES
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NUMBER
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ADDRESS
PLAT NAME:SUBDIVISION NO. L T NO. LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP 'LSCP Aporeved CI
RW Permit Req,am 0
Street use Permit Requ.red 0
EXISTING .. _ -PROPOSED .__ ._._ _ ...___ Inspeci,ce Requited 0
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REQUIRED DEDICATION FT Underground 0
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Witino required O
ME1ER SIZE LINE SIZE NO OF FIXTURES PRV REQUIRED
YES 13 NO ❑
REMARKS O
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NAME CBL# ENGINEERING REVIEWED BY DATE
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ADDRESS ./ RECYCLE REVIEWED BY DATE
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TELEPH NE PUBLIC WORKS REVIEWED BY DATE
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STATE LIC NSE NUMBER EXPIRATION DA4;E 0 BY FIRE REVIEWED BY DATE w
1,5"A.A� V*411
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VAVFANCrOR CU SHORELINE OR ADB# INSP CTION SEPA
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NEW. 1:1 RESIDENTIAL M i MI M,lp+/ MECH [3 WAIVER ALLOWED PROPOSED ALLOWED PROPOSED
❑ADDITION COMMERCIAL COMPLIANCE OR i3 STUDY
❑ MIXED USE ❑ CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT.). PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN t7
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❑ REPAIR ❑ GRADING ❑ FENCE
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( X FT.) PARKING LOTAREA PLANNING REVIEWED BY DATE j REO'D I PROVIDED
❑ DEMOLISH ❑ TANK
❑ GARAGE RETAINING CARPORT ❑ ROCKERY WALL ❑ FIREALARMRE L REMARKS
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STORIES I UNITS DWELLING TYPE OF CONSTRUCTION CODE OCCUPANT
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DESCRIBE WORK TO BE DONE.
SPECIAL INSPECTION CONSULTANT OCCUPANT
REQUIRED 0 YES LOAD
REMARKS 0
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i GEOTECH REPORT J5
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STRUCTURAL DESIGN
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EVALUATION .
Description FEE Description FEE
HEAT SOURCE LOT SLOPE% VESTED DATE Plan Check State Surcharge
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PLAN CHECK NO: j� _ Building Permit City Surcharge
Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
f DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE
SEPARATE PERMISSION. Grading
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
i PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. ReVI@W Recording Fee
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection Plan Chk. Deposit
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o •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
LU IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review Receipt #
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
sALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR BJDIRECTLY �i �+
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE Fire Inspection Total Amt. Due
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 # („
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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, 1 AGREE TO COMPLY WITH CITY AND STATELAWS REGULATING CONSTRUC• Building Olfrctal or htsrher Deputy, and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION
IN VIOLATION OF THE LAB ODE OF THE STATE OF WASHINGTON RELATING TO receipt is acknowledged m spots provided
WORKMEN'S COMPENSATI 1N ANCE AND RCW 18:27. \ A 2'iLJ J C` OFFICIALS SIGNATURE DATE
SIG E (OWNE DATE SIGNED
771 =0220 RELE Y 0 TE
TEN ON EXT. 1333 Z 6
IT IS UNLAWFUL TO USEVOEEN
PY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HMADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCYN GRANTED. UBC
/ IBC110 / IRC110, RI AL -FILE v 'OW -INSPECTOR
PINK -OWNER •GOLD •ASSESSOR
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