20050571A (2).pdfI
GATE RECEIVED!�
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
R NAME/NAME OF BUSINESS
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MAILING ADDRESSn
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CITY ZIP I TELEPHONE
NAME CB #
ILK
ADDRESS
PERMIT EXPIRES V7,i
PERMIT
NUMBER
JOB SUITE/APT#
ADDRESS '
PLAT NAMEISUB DIVISION NO. LOT NO. LID NO.
LID FEE $ .
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TE Permit equi ❑
RW Permit Required ❑
Street Use Permit Required ❑
EXISTING PROPOSED inspection Required ❑
Sidewalk Required ❑
REQUIRED DEDICATION --pY""' " ' w underground E3,•....� a ueed ❑
MEIR SIZE LI f S R REQUIRED
Obta rt dEtr a
triesYES. NO O z
W
REMA K M ILU' j a'1 W
OWNE IC NTRACTOR RESPONSWLF,�R6eMMCOMAbL/DRAINAGE z
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f""""�" ` s rc wired.
a apPlianCCS passing
Imc
titirntip-ih unheated spaces.
FIRE REVIEWED BY
DATE
DATE
CITY .21P TELEPHONE
STATE LICENSE NUMBER EXPIRATION DATE ECKED BY VARIAN CU ,SHOR N ON E
�► 7 d. I In add tion` r�> T
'
PROPERTYTA ACCOUNTPARCELNO. CA# N . S Ifta HEI
,� v WAIVER O `1Ste expansl L�� PROP os D �nnt�OWED
STUDY O hOt► ted K3•
❑ NEW RESIDENTIAL PLUMBING / MECH AL
LOT C �E-2EOONT SETBACKS (FT.) PROPOSED SET
ALLOWED f�'SEO�j �� FRONT SIDE RE
COMMERCIAL COMPLIANCE OR ��p ^n om
❑ ADDITION ❑ '" . - ..:
❑ MIXED USE CHANGE OF USE
❑
REMODEL ❑ PARKING LOT AREA PLANNING REVIEWED BY DATE MULTIFAMILY ❑ SIGN REQ'D PROVIDED
GRADING FENCE
❑ REPAIR ❑ CYDS ❑ ( X FT.) REMARKS
❑ DEMOLISH ❑ .TANK ❑ OTHER
GARAGE RETAINING ❑ WALL FIRE CARPORT ❑ ROCKERY FIREALLER
ARM
OCCUPANT
GROUP
W
rL
EXEMPT
IT
PROPOSED
,CKS (FT.)
REAR
z
z
z
z
5
NUMBER NUMBER OF
OF DWELLING SPECIAL INSPECTION CONSUL OCCUPANT
STORIES UNITS REQUIRED YES LOAD
DESCRIBE WORK TO BE DONE
REMARKS z
j_
Iar� GEOTECH REPORT
r
BY: a0
G7� U STRUCTURAL DESIGN
BY:
VALUATION
$
l�2r l Description FEE Description FEE
Plan Check State Surcharge
HEAT SOUR SjE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAA CHECK NO: d 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
J SEPARATE PERMISSION.
rt Engr. Review
U PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
L PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATIONMISSION
Ellgf. inspection
r� 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
Aj IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
Y 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
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due
0 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 APP OVAL
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 hlslhor Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt I cknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27. IALS ATU DATE
SIGNAT (OWNER R ENTj,� DATE(425)•�SI NED
771 -0220 RELEASE BY ATE
AftS1tNTION EXT. 1333
or
IT IS UNLAWFUL TO USE OR OC U Y 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, UBC109I IBC110I IRC110. PINK -OWNER • GOLD . ASSESSOR
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