20060014 (2).pdfC DATE RECEIVED
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CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
ADDRESS �•
OWNER NAME/NAME OF BUSINESS
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1 Ot�l PLAT NAME/SUBDIVISION NO.. L NO. LID NO.
MAILING ADDRESS LID FEE S
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3 V TESCP ADprovon ❑
' • PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
� HW F?ermJ Requirnd ❑
' Street Use Permit Reqmrea ❑
CITY ZIP TELEPHONE EXISTIIJG _ ____ PROPOSED . _..__ _.._ _ _ inspection Req„aad ❑
r Sidewalk Hequaed ❑
% Underground ❑
AEQUtRED DEDICATION ___ FT _______ Wam rr: udeo ❑
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
V_0 S Ike, I YES i3 NO ❑
ADDRESS
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CITY ZIP TELEPHONE z
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NAME CBL# ENGINEERING REVIEWED BY DATE
m0 ADDRESS RECYCLE REVIEWED BY DATE
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CITY ZIP TELEPHONE PUBLIC WORKS REVIEWED BY DATE
STATE LICENSE NUMBER EXPIRATION DATE 1 l!"ECK D M* FIRER VIEWED BY DATE W
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PROPERTY TAX ACCOUNT PARCEL NO. VARIANCE OR Cu SHORELINE OR ADB# INSPECTION SEPA
V, '� O REQ'D COMPLETED EXEMPT
WAai /tj 0YES NO
CA# ZONE SIGN AREA HEIGHT
NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH O WAIVER - ALLOWED PROPOSED ALLOWED PROPOSED
COMMERCIAL COMPLIANCE OR STUDY
ADDITION ❑ ❑ CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT) MIXED USE ❑
REMODEL MULTIFAMILY ❑ SIGN ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
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❑ REPAIR ❑ GRADING CYDS ❑ FENCE z
( X FT.) PARKING LOTAREA PLANNING REVIEWED BY DATE
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DEMOLISH TANK
OTHER REO'D I PROVIDED a ❑
z ❑GARAGE RETAINING WALL FIRE SPRINKLER REMARKS
CARPORT ❑ 'ROCKERY FIREALARM
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a (TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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OF DWELLING
OSTORIES UNITS TYPE OF CONSTRUCTION CODE OCCUPANT�j
DESCRIBE WORK TO BE DONE
SPECIAL I SPECTION CONSULTANT OCCUPA T
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REMARKS
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•J L GEOTECH REPORT g
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STRUCTURAL DESIGN
BY'
$VALUATION
Description FEE Description FEE
HEAT SOURCE LOT SLOPE% VESTED DATE Plan Check State Surcharge
Building Permit City Surcharge
PLAN CHECK NO: Q _ Q
Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO MBChanICBI
(_ BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE
t SEPARATE PERMISSION, Grading
PERMIT APPLICATION: SEE ECDC 19,004005(A)(5) Engr. Review Recording Fee
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection Plan'Chk. Deposit
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*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
uj IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review --^ Receipt #
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
a ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY Total Amt. Due
= FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE Fire Inspection •--.
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.* Landscape Insp, Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT 1 AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF CALL This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO receipt Is acknowledged in space provided
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. (425)(P)jF.Rf!1Q$"SIURE ATE
S NATURE QWNER A EN DATE SIGNED'fGJnJn
771 =0220 nE ED BY I JDATE
ATTENTION EXT. 1333
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 / IRC1100
6105 PRESS HARD w YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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