20051125.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEjNAME OF BUSINESS
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MAILINGADDRESS
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CITY ZIP TELEPHONE
NAME
ADDRESS
NAME
ADDRESS
STATE LICENSE NUMBER
PROPERTY TAX A!=UN
NEW
ADDITION
REMODEL
'REPAIR
DEMOLISH
GARAGE
CARPORT
(TYPE OF USE,
NUMBER
OF
TELEPHONE
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EXPIRATIQN D4TE
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ARCELNO,
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RESIDENTIAL
COMMERCIAL
MIXED USE
MULTIFAMILY
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GRADING CYDS
[:]TANK
WALL
ERETAINING
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ROCKERY
iR ACTIVITY) EXPLAIN:
NUMBER OF
DWELLING
PERMIT EXPIRES
kRMIT
NUMBER
JOB
ADDRESS 27
SUITEiAPT#
2 A
PLAT NAME/SUBDIVISION NO,
LOT NO
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LID NO,
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
I ESrP Approwed
0
0
RW Pelm.1 Rmuited
13
EXISTING __ PROPOSED
Street Use Permit Required
Inspection Required
C3
Sidewalk Required
Q
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REQUIRED DEDICATION
FT
Underground
0
Wmnq mquired
METER SIZE LINE SIZE
F FIXTURES PRV REQUIRED
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YES 13 NOO
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REMARKS
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE Uj
VARIANCE OR CU SHORELINECRADBI I INSPEEO�ION S'EPA
R D COMPLETED I EXEMPT
13YES 13NOI
CAP ZONE SIGN AREA HEIGHT
WAIVER13 ALLOWED PROPOSED ALLOWED PROPOSED
STUDY E3 I j I
LOT COVERAGE CT PROPOSED SETBACKS (FT.)
PLUMBING I MECH ALLOWED PROPOSED FRONT SIDE REA'R FRONT UR SIDE REAR
COMPLIANCE OR
CHANGE OF USE z
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PARKING LOTARET 7PLANNING REVIEWED 13Y DATE
El SIGN REO'D I PROVIDED
FENCE
( X FT.) REMARKS
El OTHER . I
IFIRE SPRINKLER
D FIREALARM 11
TYPE OF CON
CONSULTA
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STORIES
UNITS
REQUIRED 13YES
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1-
DESCRIBE WORK TO BE DONE
REMARKS P� ."%o
GEOTECH REPO r
BY:
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STRUCTURAL DESIGN
BY:
VALUATION
$
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Description
Plan Check .
HEAT SOURQIE
LOTSLOPE%
VESTED DATE
Building Permit
PLAA CHECK NO:
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
Lit
IL
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
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'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
'G D E CTL Y OR I N I CT
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
H S P E RM T S HA LL N OT BE
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
T OF A NY C TY 0 RD' NAN C E
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
D NA CE P ROV' S 'ON "
I N
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY.TO ENFORCE ANY ORDINANCE PROVISION.,
NY OR
Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
CALL
FOR INSPECTION
JDE
N , THAT THE INFOR MATION
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
I LY AUTH ORIZED AGENT OF
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
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THE OWNER, I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
13
S WIL MP OY
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSAT I�SURANCE AND RCW 18:27.
(425)
SIGN URE (OWNER 0 AGEN
D ED
S
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7
771-0220
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OCCUPANT
GROUP
OCCUPANT
LOAD
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FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt # 0
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APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy! and Fees are paid. and
receipt is acknowledged in space provided
01
F I LS SIGNATkJR DATE
LEAsifil"By' DATE
(ATTENTION t:A L I JJJ
IT IS UNLAWFUL TO USE OR OCC A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEE(MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 I IBC110 / IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL -FILE YELLOW -INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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