20051173.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PLAT NAMEISUBDIVISION NO, LOT NO / LID NO
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Street Use Permd Requited 0
EXISTING PROPOSED ins "Ion Requited aAr
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,�{�,�' S (,(,) `j ZYl L� f , 3 �•-�� ' L_ REQUIRED DEDICATION FT _ Underground 17
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METER. LINE SIZE NO. OF FIXTURES PRV REQUIRED
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STATE LICENSE NUMBER EXPIRATION DATECHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
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PROPERTY TAX ACCOUNT PARCEL NO.
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RESIDENTIAL LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
❑ NEW KI PLUMBING / MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR m
❑ COMMERCIAL �"�•I ?
ADDITION ❑ COMPLIANCE OR;��
❑ MIXED USE CHANGE OF USE (• 7.0 ' / ��z
❑ PARKING LOTAREA PLANNING REVIEWED BY DATE
REMODEL 1:1 MULTIFAMILY REO'D 116
MULTIFAMILY ❑ PROVIDED
GRADING FENCE 7 - %' !J
❑ REPAIR ❑ CYDS ❑ ( X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
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CARPORT ❑ ROCKE Y. RETAINING WALL ❑ FIREALARM SPRINKLER
aIL (TYPE OF USE, BUSINESS OR ACT ITY,) EXPLAIN:
TYPE.OF CO C ION COOK OCCUPANT
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oNUMBER NUMBER OF
OF DWELLING � SPECIAL INSPECTION CONSULTANT OCCUPANT
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Description FEE Description FEE
Plan Check `� State Surcharge
HEAT SOURCE LOT SLOPE%a VESTED DATE
k�- Building Permit City Surcharge
PLAN CHECK NO: —
Plumbing. Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Grading
nAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
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SEPARATE PERMISSION. Engr. RE1VIeW
CK w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
CL PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
•APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
IN INTEREST,AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
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 Landscape Insp. Total Amt. Due
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt # <
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPR VAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF 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 CALL Building Official or his/her Deputy: and Foes are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN' SATION INSURANCE D RCW 18:27,
OF IALS SIGNAT DATE
SI ATU N AGENT): ' DATE SI ED J�> (425)
. ��, 771=0220 E DA
ATTENTION EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL rf G
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
ORIGINAL -FILE •YELLOW INSPECTO
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 I IRC110. PINK -OWNER GOLD - ASSESSOR
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