20051130.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
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CITY ZIP TELEPHONE
NAME
ADDRESS
C4 1 o 5 MIT EXPIRES
PERMIT
NUMBER
JOB SUITEiAPT#
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PLAT NAME!SUBDIVIS;ON NO. LOT NO. LID NO
I LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TLSCP ApplaP.13
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Street Use Perril Flecianea
EXISTING PROPOSED Inspecton Roqu ree
Side�ai� Requ,ted
REQUIRLD DEDICA1 ION FT undefgFound
Wiring fecia,led
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
I YES 13 Nob
REMARKS
OWNER,,CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ddition to the required
pressure/relief valve, an approved
[qRtFdIV9ffMffldb tank shall be DATE
ADDRESS I jRECYCLE REVIEWED BY DATE
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ZIP TELEPHONE PUBLIC WORKS REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATION DATE MK D B' FIRE REVIEWED BY —1
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El CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.) 0
MIXED USE ALLOWED PROPOSED FRONT SIDE REAR FRONT LJRSIDE REAR 0
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REMODEL' MULTIFAMILY E] SIGN z
REPAIR GRADING FENCE M
CYDS X FT.) PARKING LOTAREA PLANNING REVIEWED BY DATE M Z
REO'D i PROVIDED
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DESCRIBE WORK TO BE DONE I VA 11/) 1 . _D I . E�,_= 0 Uj
SPEC lAd INSIIiLtTIO.14 Z--' CONSULTANT OCCUPANT
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REMARKS
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Description FEE Description FEE 3:
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OEATSOURCr' VESTED DATE Plan Check State Surcharge z
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Building Permit City Surcharge C, 07; >
PLAN CHECK NO:
Plumbing Base Fee M
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
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SEPARATE PERMISSION. Grading
cc PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
uj 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
0 GAPPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESSORS
_j IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review Receipt #
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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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
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION., LandscapeInsp. Receipt
I HEREBY ACKNOWLEDGE THAT I HAVE READ TH . IS 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; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION Building Off "al o h 51her Deputy and Fees afe paid, and
to 1p is ackn�wledged in space provided
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSA;PN4N&4RANCE AND RCW 18:27. (425) Cl S IG TUR41 DAT
SIGMNER RAGE DATE SIGNED
771-0220 B DA�E
ATTENTION EXT. 1333 U
IT IS UNLAWFUL TO USE OR OCCUPY 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 / IBC110 / IRC110. PINK -OWNER GOLD ASSESSOR
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