20051163.pdfa
I DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNE
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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PERMIT EXPIRES
P�RMIT
NUMBER
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ADDRESS /
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PLAT NAM E/SUBD IV I SION NO.
LOT NO.
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LID NO,
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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13
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EXISTING PROPOSED
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SiaeAatk Required
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RLOUIRED DEDICA1 ION
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Undeiground
13
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Wring rego.red
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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YES 13 NOO
REMARKS
OWNER!CONI FACTOR RESPONSIBLE FOR EROSION CONTROLJDRAINAGE
NAME CBL# ENGINEER114G REVIEWED BY DATE
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OBSERVED BY C11'Y INSPECTOR
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STATE LICENSE NUMBER EXP11IO DATE W E Y BE AGGEPTEB DATE
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GRADING
CYDS
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TANK
OTHER
RETAINING WALL
FIRE SPRINKLER
ROCKERY
FIREALARM
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NUMBER OF
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LOT COVERAGE REQUIRED SETBACKS (FT.) I PROPOSED SETBACKS (FT)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/RSIDE REAR
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REMARKS
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GEOTECH REPORT
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STRUCTURALDES11
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VALUATION
Description
Plan Check
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LOT SLOPEO,6 _____jVESTED
DATE
Building Permit
PLAN CHECK NO:
Plumbing
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Mechanical
Grading
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, Review
Engr. Inspection
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Fire Review
Fire Inspection
Landscapelnsp.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF CALL
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
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPE�=ANCE AND RCW 18:27.
(425)
SIGNATU*(OWNE 0 AGEN.): DAT IG -0220
1 771
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EXT. 1333
ATTENTION
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 / IRC110.
OCCUPANT
GRO
OCCUPANT
LOAD
FEE Description
State Surcharge
City Surcharge
TT_ IBase Fee
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FEE
Recording Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
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APPLICATION APPROVAL
This application is nor a permit until signed by the
Building official or his/her Deputy and Fees are paid, and
receipt is acknowledged in space provajed
RELEASED
6/05 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL -FILE YELLOW -INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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