20050311.pdfDATE RECEIVED q
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OY�NER NAME/NAME OF BUSINESS
MAILIN ADDRESS
CITYZIP TELEPHONE
NAME
ADDRESS
NAME CBL#
ADDRESS
I'1 [PERMIT EXPIRES_
PERMIT
Vr 3
NUMBER
JOB SUITE/APT#
ADDRESS
46) 111 JJ
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PLAT NAME/ UBDIVISION NO. LOT NO. LID NO.
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved
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ENGINEERING REVIEWED BY r " DATE
FIRE REVIEWED BY DATE
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STATE LICENSE NUMBER EXPIRATION DATE CHCKED BY VARIA CFa4R> i t ECT
S}10RE LI�� ;FiA # CINSP110�K ET D 115EP EXEMPT
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PROPERTY TAX ACCOUNT PARCEL NO. CA# �' • TZONE� �� H �GHT
ff WAIVER ^ `• « .. •,.. ,. •..... PROPOSED
W S U G� STUDY E3
❑ NEWRESIDENTIAL r;Uop[UMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
COMMERCIAL COMPLIANCE OR
❑ ADDITION ❑ MIXED USE CHANGE OF USE
❑
;iiFi�'7REMODEL PARKING LOT AREA. PLANNING REVIEWED BY DATE.
)REMODEL ❑ SIGN REQ'D PROVIDED
❑ REPAIR ❑ GRADING FENCE
CYDS ❑ X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
GARAGE z ❑ CARPORT ❑ RETAINING WALL LER
ROCKERY ❑ FIREALARM
a(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
a `;� 1 NSTRU TION CODE OCCUPANT
U
oNUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
p STORIES UNITS LOAD
-� REQUIRED 13 YES
DESCRIBE WORK TO BE DONE
REMARKS
�� i GEOTECH REPORT
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BY:
STRUCTURAL DESIGN
// BY:
i (Q VALUATION
t " Description FEE Description FEE
Plan Check State Surcharge.
HEAT SOURCE LOT SLOPE% VESTED DATE 5 60
Building Permit City Surcharge ,
PLAN 161JECK 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
ra
IN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
SEPARATE PERMISSION, Engf. ReVIBW
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
in *APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
W 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 Vill
= FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
C DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due
01- 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 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• CALL Building Official or his/her Deputy, and Foes aro paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged in space provided
IN VIOLATION OF THE LABOR CODE HE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURA CE AND CW 18:27.
OFFI GN RE DA E
SIGNAT Rt (OWNER OR GEN DATE SIGN )D tt/ t—_ (425) t `� 2
771 -0220 REL A ED BY L DAIE
I-
ATTENT N EXT. 1333
IT IS UNLA FUL TO EOR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL I ON HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL FILE YELLOW • INSPECTOR .
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC1101 IRC110, PINK -OWNER • GOLD • ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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