20050902.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAJ OF BUSINESS
W MAILING ADDRESS
CITY ZIP TELEPHONE
NAME
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PERMIT
NUMBER
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PLAT NAMEISUBDIVISION NO. { LOT NO. LID NO.
LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved ❑
RW Parmil Required ❑
Street Use Permit Requited ❑
EXISTING PROPOSED Inspection Requited ❑
-- Sidewalk Requited ❑-
REQUIRED DEDICATION FT Underground ❑
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Mine re tared ❑
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YESE3 N013 z
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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ADDRESS
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FIRE REVIEWED BY DATE W
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STATE LICENSE NUMB`E'R EXPIRATIONDATE BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
r+# REO'0 COMPLETED EXEMPT
lqp 10YES ONO
V (_) CA# ZONE SIGN AREA HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO.
D D WAIVER D ALLOWED PROPOSED ALLOWED PROPOSED
STUDY O
❑ NEW 1� RESIDENTIAL ❑ PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.), PROPOSED SETBACKS (FT.)
��� 1�\ ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR O
1:1 COMPLIANCE COMPLIANCE OR
❑ ADDITION ❑ CHANGE OF USE i
❑ MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g
❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
,REPAIR ❑ GRADING CYDS ❑ FENCE X FT.) REMARKS
❑ DEMOLISH ❑ TANK OTHER
GARAGE RETAINING FIRE
❑ CARPORT ❑ .ROCKERY WALL ❑ FIREALARM SPRINKLER
(TYPE OF USE, BUSINESS OR AFXPLAIN:
P FC NST CTION C OCCUPANT �J
GROUP K
NUMBER NUMBER OF
OF DWELLING SPECIAL I PE TION CONSULTANT OCCUPANT
STORIES UNITS LOAD,
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DESCRIBE WORK TO BE DONE ; — _ REQUIRE YES1111 1
STRUCTURAL DESIGN
BY:
VALUATION
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qb Description FEE Description FEE
2003`0k6Zo lewo Plan Check tj Slate Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit 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
SEPARATE PERMISSION,
Engr. Review
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 INFORMATION Engr. Inspection
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORSFire Review Plan Chk. Deposit
u 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
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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 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 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 receipt is acknowledged in spare provided.
FOR INSPECTION
WORKMEN'S.0 NSATION INSURANCE AND RCW 18:27. OFFICIAL NATURE DATE
SIGNATURE WNE OR AGENT DATE NED (425)
TOY
,`i'.!z'Jl" V 5' 771-0220 RELEA Y DATE
ATTENTIO IEXT 1333
IT ISUNLAWF TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI• ORIGINAL FILE YE LOW • 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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