20051154.pdfDATE RECEIVED 11
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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NAME
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TELEPHONE
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NAME
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[PERMIT EXPIRES
PERMIT
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NUMBER
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ADDRESS
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7LAT NAMEiSUBOIVISION NO.
LOT NO.
LID NO�
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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METER SIZE
LINE SIZE
NO� OF FIXTURES
PRV REQUIRED
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE4
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PROPERTY TAX ACCOUNT PARCEL NO.
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GARAGE
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FIRE SPRINKLER
CARPORT
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FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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VARIANCE OR CU SHORELINE OR ADB4 INSPECTION SEPA M
REQ'D COMPLETED EXEM PT
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[3 WAIVER 94 ALLOWED PROPOSED ALLOWED PROPOSED
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LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) M
ALLOWED PROPOSED 0
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TYPE OF CONSTRUCTION CODE OCCUPANT
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REQUIRED 0 M
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GEOTECH REPORT D --i
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De'scription
FEE Description FEE
HEAT SOURH_7 LOT SLOPE% ___7ESTED DATE
F
Plan Check
State Surc
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PLAN CHECK NO:
�5 14
Building Permit
City Surcharge
0
-4
0
Plumbing
Base Fee
ITI
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
j SEPARATE PERMISSION.
It=
Grading
Lu 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
*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 -7
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
4 ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
Fire Inspection
Total Amt. Due
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
0j 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.*
Landscapelnsp.
Receipt
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
Tnis application is not a permit until siglind 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
FOR INSPECTION
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
receipt is acknowledged in space provided
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
(425)
OFFICIALS SIGNATURE DATE
SIGNATUR: DATE SIGNED
771-0220
% A A
7 .�
—AELV164--fty DATE
EXT. 1333
V,
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE,AND APPROVAL OR A CERTI
GINAL - FILE YELLOW - INSPECTOR
FICATE OF OCCUPANCY H AS BEEN GRANTED. UBC109 if IBC110 / IRC110.
INK -OWNER GOLD - ASSESSOR
6105 PRESS HARD - YOU ARE MAKING 4
COPIES
FINAL PROJECT APPROVAL FORM