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CONSTRUCTION PERMIT APPLICATION JOB SUITEIAPT#
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OWNER AME/NAME OF SINESS li
X PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
MAILING ADDRESS LID FEE 5
O r n�' n PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Pe mitApproved
Required ry l� /` %%% TE Permit r o ed
Street Use Permit Required
CITY ZIP TELEPHONE EXISTING PROPOSED-.. Inspection Required O
mom ON s 9' oafo c 5 � ��' L OCG Wi;mg tk Required
REQ IR604)40IC 74QI4.•+.�••-...•...-•o Al. Undoriround O
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NAME ME E' 3ta1 i Eleut i al NpeFfffiftEf'f %.,fRy REQUIRED
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STATE LICENSE NUMBER EXPIRATI DATE D BY VARIANCE OR CU ��� AV y1S��� �Ncj, ETED P EXEMPT
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❑ NEW �. RESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBAC S ( T.) OPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIR SIDE REAR
❑ COMMERCIAL COMPLIANCE OR i
ADDITION❑ MIXED USE ❑ CHANGE OF USE z
❑ PARKING LOT AREA PLANNING REVIEWED BY DATE 5
❑REMODEL
MULTIFAMILY ❑ SIGN REQ'D PROVIDED IL
❑
REPAIR ❑ GRADING CYDS ❑ FENCE X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
_ ❑GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ❑ ROCKERY ❑ FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPL
� TYPE N T TION OCCUPANT
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NUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
MSTORIES UNITS LOAD
REQUIRED DYES
DESCRIBE WORK TO BE DONE /� J
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,I6 Description FEE Description FEE
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16711011 Plan Check State Surcharge
,AAT SOURCE LOT SLOPE% VESTED DATE
l/�'TAT Building Permit City Surcharge % --
PLAN CHECK NO: Plumbing Base Fee r
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
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE g
t SEPARATE PERMISSION.
Engr. Review
Lu PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
IL 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
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IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
Ir EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #.
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
G DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due
O NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
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Recording Fee Receipt #
1 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 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 Oeipt i or his/her dgediDeputy: and Fees are paid; and
IN VIOLATION OF THE LAB O ODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATIO U NCE AND RCW 18:27.
OFFICIALS SIGNAT RE
SIGNATU E (OWNER OR EN DATE SIGNED (425) % .
1 iI-Ij 771 w0220 REL( rDAT
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- ORIGINAL FILE YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC1106 PINK -OWNER GOLD - ASSESSOR
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