20050184.pdfGATE RECEIVED r ) 1 L���
.5 O� PERMIT EXPIRES (.
CITY OF EDMONDS NUM ER c,X5"(>)
CONSTRUCTION PERMIT APPLICATION JOB SUITEIAPT#
ADDRESS
OWNER NAMEINAME OF BUSINESS l
C PLAT NAME/SUBDIVISION NO, LOT NO. LID NO
UM MAILING ADDRESS ` LID FEE S
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1 ' ��( �� PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW CP PermitReqApproved O
O �' Q \ r RW Permit Required �
Street Use Permit Required E3
CITY ZIP TELEPHONE EXISTING PROPOSED Inspection Required O
\ S,tlowalk Required 13
FT ,\ Underground 0
t- --�11- �, ! ! REQUIRED DEDICATION _ _ _ _
Witing re cued O
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 13 NO O z
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t ADDRESS REMARKS w
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csi OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VA hNCq"bB U 1 ( Il'm9 � �17zirt' r Ace PT
G"OUNND NG 1S ALT OI✓0 t
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E] NEW . RESIDENTIAL pLUMBI MECH COT COVERAGE ` ' ktaUli7EOvSE`h!rW t (FT.) PROPOSED SETBACKS (FT.
AR I FRONT LIR SIDE REAR 0
❑ COMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑ MIXED USE ❑ CHANGE OF USE i
❑REMODEL ❑ PARKING LOT AREA PLANNING REVIEWED BY DATE 5
MULTIFAMILY ❑ SIGN REO'D PROVIDED
❑❑ GRADING ❑ FENCE X FT.) REMARKS
REPAIR. CYDS (
❑ DEMOLISH ❑ TANK ❑ OTHER
Z D GARAGE RETAINING CARPORT ❑ ROCKERY WALL ❑ FIRE ALARM
FIRE KLER
a(TYPE OF USE, BUSINESS OR ACTIV Y) E IN.
TYPEto
UCTION QQ OCCUPANT
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NUMBER 'n NUMBER OF S
OF �/ DWELLING I SPECIAL INSPECTION CONSULTANT OCCUPANT
p STORIES UNITS LOAD
DESCRIBE WORK TO BE DONE REQUIRED YES
REMARKS z
GEOTECH REPORT :2
BY: m
STRUCTURAL DESIGN
BY:
VALUATION
$
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE �^
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 Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE g
SEPARATE PERMISSION.
Engr. Review
Lu PERMIT APPLICATION: SEE ECDC 19,00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19,00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
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*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk, Deposit
Lu IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS* WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
a 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 k ._) (,
I 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 pennd 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 Oulpf i or funowl Deputy and Foes are paid, and
IN VIOLATION OF THE LAB ODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION roceipt is acknowledged ut spear provided
WORKMEN'S COMPENSAT IN NCE AND RCW 18:27,
OFFICIALS IGNATURE A7r
SIG AT'UnRE (OWNER O GENeel
( L Ll DATE SIGNED r' ` (425) JV I [ I` L /1:�
is Jl i �KC��V 14 I CY ��1 -U22U RELEASED BY UAT
ATTENTION EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING 6R STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTle ORIGINAL • F11.E • YELLOW INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 L IBC110 I IRC110. PINK • OWNEI< • GOLD ASSESS011
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