20050411.pdfDATE
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
CITY ZIP TELEPHONE
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NAME
ADDRESS
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PERMIT EXPIRES
P
ERMIT
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BDIVISION NO. LOT NO. LID NO.
LID FEE S
OF WAY PER OFFICIAL STREET MAP TESCPApprovud O
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STATE LICENSE NUMBER EXPIRATIOt D E CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTIO14 SEPA
/� REQ'D COMPLETED EXEMPT
)� b 13 YES i3 NO
PROPERTY TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT
`� `O .` ` 1 O V WAIVER 13 ALLOWED PROPOSED ALLOWED PROPOSED
S STUDY 0
1:1 NEW • RESIDENTIAL PLUMBING / MECH LOT COVERAGE ) OPOS,pE�D ETBACKS (FT.)
P > GUR V ,^ 7 SIDE REAR
ADDITION LJ COMMERCIAL COMPLIANCE OR
1:1 1:1CHANGE OF USE S BE ]N,STALL"
❑ cc�� z MIXED USE PARKING BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑. SIGN. REQ'D PROVIDED
❑ REPAIR El GRADING GRADING ❑ FENCE X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
❑RETAININGGARAGE WALL LER
CARPORT ❑ ROCKERY ❑ FIREALARM
TYPE OF NSTRUCT ON CODE
U
w NUMBER INUMBER OF
OF DWELLING SPECT L INSPECTION CONSULTANT
WSTORIES - UNITS
REQUIRED 0 YES
DESCRIBE WORK TO BE DONE
REMARKS
A ` ` \ h f C .� GEOTECH REPORT
BY:
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C ' \ • V ^ ` STRUCTURAL DESIGN
BY:
VALUATION
$
Description FEE
Plan Check
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit
PLAN CHECK NO: Plumbing
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
SEPARATE PERMISSION, Engf. Review
w 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. II1SpeCtlOn
OCCUP
GROUP
OCCUPANT
LOAD
Description
State Surcharge
City Surcharge
Base Fee
FEE
V)•APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
�
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
Ix
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. • ,I
Recording Fee Receipt # 7
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 This application is not a permit until signed by the
THE OWNER. 1 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 Official or hislher Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATION URANCE AND RCW 18:27.
OF IALS SIGNA RE DTE
St NTU E (OWNER O NT : DATE SIGNED (425)
L21 k
1�AA 1?/ _ OS 771 =0220 RELEA DTE
ATTENTIO EXT. 1333
IT IS UNLAWFUL O 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. UBC1091 IBC1101 IRC110. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES.
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