20050779.pdfDATE RECEIVED
PERMIT EXPIRES _
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CITY OF EDMONDS NUM ER !)C�c�- u l / 17
CONSTRUCTION PERMIT APPLICATION
O ER NAME/NA OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME 7
ADDRESS
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ADDRESS f; 7/
PLAT NAME/SUBDIVISION NO.NO
LOT .7 LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP 'lESCP Approved O
RW Permit Required
Street Use Permit Required E3
EXISTING PROPOSED._ inspection Required O
Sb )walk Required E3
REQUIRED DEDICATION FT Underground O
shoo re cared O
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES i] No 17 Z
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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ENGINEERING REVIEWED BY
DATE
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FIRE REVIEWED BY DATE LUZ
o CITY ZIP TELEPHONE O
STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA t7
% REO'D COMPLETED EXEMPT M
` t moeawIvyA t p M GY✓ %F,� / 0 YES NO
CA# hl ZONE SIGN AREA HEIGHT �.
a PROPER TAX ACCOUNT PARCEL NO. T —
C, WAIVERO ALLOWED PROPOSED ALLOWED PROPOSED Omni ;zooSTUDY o R's" 1� D _
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❑ NEW ® RESIDENTIAL❑ PLUMBING / MELOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.) C
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR M O
❑ ADDITION ❑ COMMERCIAL ❑ COMPLIANCE OR 3�C'� NP �!.HA44cor Al O (�H. �-N e ? O
❑ MIXED USE' CHANGE OF USE
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PARKING LOTAREA PLANNING REVIEWED BY DATE g
❑ REMODEL( .I� ❑ MULTIFAMILY ❑ SIGN N o PROVIDED M 2 ` _
_ � L/-1 o (� E),5' � i m z
REPAIR FENCE Q "I
❑ GRADING CYDS ❑ ( X FT.) REMARKS C --
❑ DEMOLISH❑ TANK ❑ OTHER _ p r
GARAGE RETAINING WALL FIRE SPRINKLER O L
T T N V d
_ ❑.CARPORT ❑ ROCKERY ❑ FIREALARM
a(TYPE OF USE USINESS OR ACTIVITY) EXPLAIN:
� l TYPE OF O STRUCTION CODE OCCUPANT ^
�S / Ir GROUP (//�
oNUMBER NUMBER OF jjj 111
OF DWELLING SPECIAL IlSrSPECTION CONSULTANT OCCUPANT
o STORIES UNITS LOAD C
REQUIRED E3 YES O r—
DES E WORK TO BE DONE 1 0 Ifo
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GEOTECH REPORT m : Z r
BY:
STRUCTURAL DESIGN X
BY:
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bS Description FEE Description FEE _
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Plan Check State Surcharge z
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge j n
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PLAN CHECK NO: Plumbing Base Fee ,
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical
C 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
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
n PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
rn '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
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EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt # �S
= 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 #
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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Foes are paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged to space provided
WORKMEN'S COMP NSATION INSURANCE AND RCW 18:27,
FI LS SIGNAT E AT
SIG R OWN O NT), DAT IGGNEEDD D (42�y5)
771-022 EL E DAT
ATTENTION EXT. 1333D
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL of 7,
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- oRl NAL -FILE YELLOW - IN EC OR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC1091 IBC110 1 IRC110. �. P K -OWNER • GO - ASSESSCt
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