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241 6TH AVE S
The City of Edmonds
APPLICATION
for
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SIDE SEWER PERMIT
IDE ❑ INSIDE ❑ REPAIRS ❑
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EASEMENT No. ......................................
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CONTRACTOR ........... �:. 6�..Y...1..I.JT....--......-�� ("�....................................... --...- PERMIT N .. .�1..-
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BACKFILL WOR
SEWER WORK (
ATE RECEIVED
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PERMIT �27`
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EXPIRES
CITY OF EDMONDS
USE PERMIT ^,
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CONSTRUCTION PERMIT APPLICATION
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NAME/NAME OF BUSINESS
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
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MAILING ADDRESS
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LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
aw perm aeq ed
Street Use Permit Req'd
CITY ZIP
TELEPHONE
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EXISTING_,_._ PROPOSED
inspection Required
Sidewalk Required
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REQUIRED DEDICATION FT
Underground
Wiring required Q
NAME
METER SIZE LINE
SIZE
NO. OF FIXTURES
PRV REQUIRED
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YES NO P
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ADDRESS
REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FQR EROSION CONTROL/DRAINAGE
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CITY ZIP
TELEPHONE
NAME � � �i
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ENGINE I Effj� DATE
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ADDRESS
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FIRE REVIEWED BY DATE
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CITY ZIP
TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE
CHECKED BY
VARIANCE OR CU
SHORELINE OR ADBN I
INSPECTION
REQ'O
BOND
POSTED
DYES 13N0
$
SEPA REVIEW
SIGN AREA
HEIGHT
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PROPERTY TAX ACCOUNT PARCEL NOJ.�
COMPLETE
EXEMPT
ALLOWED
PROPOSED
ALLOWED
PROPOSED
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EXP
❑ NEW
� RESIDENTIAL
0 PLUMBING / MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS FT,
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FONT UR SIDE REAR
ADDITION
COMMERCIAL
COMPLIANCE OR
❑ CHANGE OF USE
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❑ REMODEL
❑ MULTIFAMILY
❑ SIGN
PARKING
REO'D I PROVIDED
LOT AREA
PLANNING REVIEWED BY DATE
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El REPAIR El GRADING CYDS FENCE X FT)
REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
RETAINING Y1ALL ❑ SPRINKLER
❑ ❑
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CARAGE RPORT ROCKERY FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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CHECKED BY
I TYPE OF NSTRU TION
CODE"
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OCCUPANT
GROUP 1,
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NUMBER
OF
NUMBER OF
DWELLING
CRITICAL
AREAS ! �..
IIM "`
SPECIAL INSPECTION
AREA
OCCUPANT
OSTORIES
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UNITS
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NUMBER /'+T
REQUIRED ❑ YES
LOAD
DESCRIBE WORK TO BE DONE (I Q�7
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REMARKS
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PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REII
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VALUATION
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Description
FEE
Description
FEE
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Plan Check
State Surcharge.
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HEAT SOURCE
GLAZING %
LOT SLOPE %
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Building Permit
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City Surcharge
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PLAN CHECK NO: -
VESTED DATE
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Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL
SEPARATE PERMISSION.
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PERMIT APPLICATION: 180 DAYS
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PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspecti
,
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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APPLICANT ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
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IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt N
t
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 Ins
p p
% SG
Total Amt. Due y
M.
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
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
APPLICATION
APPROVAL
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
This application is not a pervd -rnf >+� ey Vv
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATIO IF"TM� LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
Building Official or his/her Dep-rj: Ac.: rues, am art, ace
receipt is acknow1-+oy�a: n sF,ro, a*a+cra
WORKMEN'S GOMPENSATI10N INSURANCE AND RCW 18.27.
OFFI I� LS SIGNATURE P-Aaj
SIGNNATUR 9WNE P'A ENT) yy7�,
DATE SIGNED
(425)
C,.
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;77--'
771-0220
I r ,f(
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R ASED BY /s.-F
ATTENTION
M 1333
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IT I$ UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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04/02
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