20051135.pdfDATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PLATNAME/SUBDIVISION NO, LOT NO. LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TLSCP Anwo ooa
HW Perms Regwled
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EXISTING_ _:.- .._._ -. PROPOSED. _--- --- Inspeclon Required
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METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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PROPERTY TA ACCOUNT' PARCEL NO. REO'D CoraPLEtED Exet�Pt
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❑ NEW ❑ RESIDENTIAL PLUMBING7MECH 13 WAIVER p c ALLOWED PROPOSED %1iLLOWED *lloPosED
COMMERCIAL COMPLIANCE OR ❑STUDY
❑ ADDITION ❑ CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.)
❑ MIXED USE ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
REMODEL ❑ MULTIFAMILY ❑ SIGN
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❑ REPAIR ❑ GRADING ❑ FENCE Z
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❑ DEMOLISH ❑ TANK ❑ N p LN �C (� I G 1 Z10r61 D 5"
❑ GARAGE ❑ RETAINING WALL ❑ FIRE SPRINKLER REMARKS
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GEOTECH REPORT
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V STRUCTURAL DESIGN
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VALUATION
Description FEE Description FEE
HEAT SOURCE LOT SLOPES; VESTED DATE Plan Check State Surcharge
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PLAN CHECK NO: Building Permit City Surcharge
%'' Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO MBChanIC21
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
t SEPARATE PERMISSION, Grading
M 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 Plan Chk. Deposit
In M•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 ��� r
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EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
i ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY Fire Inspection Total Amt. Due
G FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE p
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINA14CE
J = NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*Landscape Insp. Receipt fl
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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, 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 g Deputy* and Fees are paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO receipt is acknowledged in space provided
WORKMEN'S COMPENSATION INSURANCE AND RCW 10:27, (425) FT'IBtt SIGN DATE
SIGNATURE WNE G NT DATE SIGNED 771 -6on`Gno / 1' / /✓
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A ENTI EXT. 13337 <
IT IS. UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 / IBC110 / IRC11 O. ORIGINAL -FILE YELLOW -INSPECTOR
PINK • OWNER GOLD ASSESSOR
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