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�� 1ZI C) PERMIT EXPIRES _ U'
CITY OF EDMONDS NUMBER 2JO5. I I �-
CONSTRUCTION PERMIT APPLICATION JOB `S < SUITEIAPTn
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OWNERrNAME/NAME F BUSINESS `
kl r 1 (YH /1 S I M /� V � Tot PLAT NAMEYSUBDIVISION NO. LOT NO. LID NO
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MAILING ADDRESS 4 / s 1 l �1 LID FEE S
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30 (/`/ ` l�1 v� PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TL Permit roved tl [3
CITY ZIP TELEPHO E EXISTING _. Street use Permit Regared O
__.___....__. PROPOSED _.._._.__ _. __._._. Inspeco,onRegwrea 13
Sweaaie R"U'red 17
{/k/r •�O�,D �� `� D �a �% '/ REQUIRED DEDICATION FT Underground C3
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NAME METER SIZE LINE SIZE NO, OF FIXTURES PRV REQUIRED
YES ❑ NO ❑
ADDRESS REMARKS 0
b1/� ` 1 OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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NAME CBLq ENGINEERING REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATI N DATE CHECKEDT3Y FIRE REVIEWED BY DATE w
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J PROPERTY TAX ACC9UNT PA CEL N0. VARIANCE OR CU SHORELINE OR ADBa INSPECTION EPA
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❑ NEW K I RESIDENTIAL PLUMBING I MECH LAI R+ ALLOWED PROPOSED ALLOWED PROPOSED
❑� 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 CYDS ( X FT.) PARKING LOT AREA PLANNING REVIEWED BY DATE a
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OTHER REO'D I PROVIDED DEMOLISH
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CARPORT 00 p�LA4 �' ❑ FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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NUMBER NUMBER OF
M OF / DWELLING TYPE OF CONSTRUCTION CODE OCCUPANT
o STORIES V1 (iM +� UNITSI N GROUP
.DESCRIBE WORK T BE DONE z
SPECIAL INSPECTION CONSULTANT OCCUPANT
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Description FEE Description FEE
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HEATS LOT SLOPE°6 VESTED TE Plan Check State Surcharge
CHECK N0: Building Permit City Surcharge
PLAN C.- O
Plumbing Base Fee
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
t SEPARATE PERMISSION. Grading
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Lu PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Engrg Review Recording Fee
0. PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection Plan Chk. Deposit
N '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 #
i EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
q 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 p
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.' Landscape Insp. Receipt #
I HEREBY ACKNOWLEDGE THAT 1 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 CALL This application is not a permit until signed 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
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 receipt is acknowledged to space provided
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. ,425 F' IALS SIGN VE DATE
SIGNATURE (OWNER OR ): DATE SIGNED
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ATTENTION ✓� EXT. 1333 L�
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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