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. DATE RECEIVED
PERMIT EXPIRES
CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB ' SUITE/APTn
ADDRESS rte {" /`^1_ • /cc /of,
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OW E NAME/NAM OF BUSINESS ) `"�J 7/�( `
L.•1 � PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
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3ft� PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApprovea C30 (/ S i �' 1- l U �„ /�--RW Perms Rega,rco C3
CITY ZIP4 TELEPHONE EXISTING _ .___ Surat use Perm,t Regwred ❑
W .____.._.PROPOSED._ _. __.._ ___ SsaeAlnspelx Required ❑
SbeMal« Required ❑
REQUIRED DEDICATION FT _ _ Undergroana ❑
Wmnr re wrea ❑
NAME METER SIZE LINE SIZE [NO, OF FIXTURES PRV REQUIRED
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YES i7 NO ❑
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I: ADDRESS REMARKS
U OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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"type I3 or, vent; connectors required
NAME CBLO ENGINE yning appliances passingDATE
through unheated spaces. IMC 8012
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PUBLIC WORKS REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATION,pA JC;HYECkBYFIRE REVIEWED BY DATEW"/L7j W
VARIANCE OR CU SHORELINE OR ADB# INSPECTION EPA
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REQ'D COMPLETED EXEIdPT
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CA# ZONE SIGN AREA HEIGHT.
❑ NEW RESIDENTIAL PLUMBING? MECH ❑ WAIVER ALLOWED PROPOSED ALLOWED PROPOSED
COMMERCIAL COMPLIANCE OR ❑ STUDY
❑ ADDITION ❑ CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
MIXED USE ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN z
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❑ REPAIR ❑ GRADING CYDS❑ ( X FT.) PARKING LOT AREA PLANNING REVIEWED BY DATE a
❑❑ ❑ OTHER REO'D I PROVIDED
DEMOLISH TANK
z 1:1GARAGE RETAINING FIRE
CARPORT ElROCKERY WALL ❑ FIREALARM SPRINKLER REMARKS
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m OF DWELLING J TYPEF STRUCTIO CO E OCCUPANT
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DESCRI E W RK TO BE DO E /v
SPECIAL INSPECTION CONSULTANiptT OCCUPANT
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REQUIRED YE4! 1 "� 3
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STRUCTURAL DESIGN E r• r - r
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$VALUATION
Description FEE . Description FEE
HE 011AC L TSLOPE96 VESTCED/DATE Plan Check State Surcharge
Lt Building Permit City Surcharge
PLA CHECK NO:.
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
9 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
I= SEPARATE PERMISSION, Grading
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Review Recording Fee
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
.iIN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review Receipt H
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
a
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY Fire FlInspection Total Amt. Due
x FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE p
0 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 #1131
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 or his/her Deputy, and Fees are paid. and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged to space provided
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. �� 4 O �O F'r•I 4,A1 DATE
SIGNAT E(OWNER OR N DA E SIGN D 1�EAS ATE
EXT. 1333
A T NTION
IT IS UNLAWFUL TO USE ORCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL - FILE YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC110 / IRC110, PINK -OWNER GOLD ASSESSOR
6105 PRESS HARD - YOU. ARE MAKING 4 COPIES