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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
tW LuY MAILINGADDRESS
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CITY ZIP TELEPHONE
NAME
ZIP ITELEPHONE
PERMIT EXPIRES
PERMIT a; NUMBER 30—�jIIJ
JOB SUITEIAPT#
ADDRESS
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PLAT NAME/ SUBDIVISION NO. LOT NO. LI N .
LID E 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP 7ESCPApproved l]
RW Permit Required E3
Street Use Permit Required 0
EXISTING PROPOSED Inspection Required O
Sidewalk Required 0
REQUIRED DEDICATION _ FT underground O
Wainq re cared E3
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES O NO 10 z
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGEz
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ADDRESS pp
FIRE REVIEWED BY DATE UJI
CITY ZIP TELEPHONE
IlL LeL -T Tb STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADBN INSPECTION SEPA
REO'D COMPLETED I EXEMPT-
IO YES 13NO
u F- 8 400 • Z.vc,
PROPERTY TAX ACCOUNT PARCEL NO. CA# ZONE SIGN AREA HEIGHT
WAIVER ALLOWED PROPOSED ALLOWED PROPOSED
go&i 3 a g o o O 3iln� I STUDY .0
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LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
RESIDENTIAL
❑ NEW 1:1PLUMBING / MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT. UR SIDE REAR
❑ COMMERCIALCOMPLIANCE OR z
❑ ADDITION ❑ MIXED USE ❑ CHANGE OF USE z
PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
GRADING FENCE
❑ REP ❑ CYDS ❑ ( X FT.) RE RKS 1
DEMOLISH ❑ TANK ❑ OTHER r
GARAGE RETAINING WALL FIRE SPRINKLER
❑ CARPORT ❑ ROCKERY ❑ FIREALARM
(TYPE OF USE, BUSINESS R A IVITY) E PLAIN:
j TYPE IONSTRUCTION CQDE� GROUP
NUMBER 1 NUMBER OF U J
OF DWELLING l SPECIAL INSPECTION . CONSULTANT OCCUPANT
STORIES UNITS LOAD
REQUIRED YES
DESCRIBE WORK TO BE DONE
REMARKS z
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GEOTECH REPORT m
BY:
e-Aarin gab, go Lai Qa k �� %kj STRUCTURAL DESIGN
BY:
VALUATION
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit S, 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
E DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS; MARQUEES, ETC.) WILL REQUIRE Grading
iSEPARATE PERMISSION, Engf. ReVI@W
r PERMIT APPLICATION: SEE ECDC 19,00,005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)rn
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engf. InSpeCllOn ,
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*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
E EDMONDS, WASHINGTON, ITS OFFICIALS; EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
= ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscape Insp. Total Amt, Due
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.'
Recording Fee Receipt #
1 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. I AGREE TO COMP Y WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL Building official or his/her Deputy: and Foes are pard, and
TION; AND IN INOiHE HORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged in space provided.
IN VIO N OF THE BOR COD THE STATE OF WASHINGTON RELATING TO
WO EN'S CO �E \ ATION IN�9 RANCE RCW 18:27, O IAL AT I IATE
E O ER AGENT): DATE SIGNED (425) A.
6:2 i� J S 771 -0220 RELEASED Y ATE
ATT TION 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, UBC1091 IBC110 I IRC1100 PINK .OWNER • GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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