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22515 96TH AVE W
DATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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NAME
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CITY ZIP E
NAME
fPERMIT EXPIRES
USE
PERMIT
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NUMBER
JOB
ADDRESS
SUITE/APT#
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
TESCP Approove
C3
,PUBLIC RIGHT 0 F WAY PER OFFICIAL STREET MAP
RW Permit Required
0
Street Use Permit Req
0
EXISTING PROPOSED
Inspection Required
Sidewalk Required
0
0
REQUIRED DEDICATION _�
FT
Underground
I Wiring required
0
METER SIZE
LINE SIZE
NO. OF FIXTURES
RV REQUIRED
YEPS 0 NO 0
7EMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTRoL/DRAINAGE
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ENGINEERING REVIEWED/DATE
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BOND
VARIANCE OR CU
SHORELINE OR ADB#
INSPEEOCTION
STATE LICENSE NUMBER EXPIRT/IO-,NDATE
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POSTED
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SIGN A E
HEIGHT
COMPLETE
10W�Eb PROPOSED
ALLOWED PROPOSED
PROPERTY TAX ACCOUNT PARCEL NO.
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3 00
0200
EXP
LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
0 NEW
RESIDENTIAL
PLUMBING MECH
ALLOWED PROPOSED
FRONT- SIDE REAR
151
FRONT U SIDE REAR
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0 AUDITION
0 COMMERCIAL
o COMPLIANCE OR
C�ANGE OF USE
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PARRING
LOT AREA
P
ED ATE
0 REMODEL
0 APARTMENT
0 SIGN
REO'D
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I PROVIDED
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0 GRADING
0 REPAIR CYDS
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0 X FT)
REMARKS iFor irX I eM AM),
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(JARAGE
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RENEWAL
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CHECKEDBY.
0 0 TF3U CTION
CODE
OCCUPANT
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GROUP
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NUMBER
NUMBER OF
CRITICAL
AREAS
OCCUPANT
SPECIAL INSPECTOR
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DWELLING
UNITS
N UMBER
rREA
REQUIRED 0 YES
LOAD
0 STORIES
atir
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
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2
VALUATION
FEE
PLAN CHECK FEE
-AZING %
LOT SLOPE %
BUILDING
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uCAT SOURCE
—FL—AN CHECK NO:
VESTED DATE.
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MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORKTO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
GRADING/FILL -51
rwr,&L
J SEPARATE PERMISSION.
BW&SURCHARGE a
PERMITAPPLICATION: 180 DAYS
PERMIT LIMIT* 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT. FOR MORE INFORMATION
'APPLICANT ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESOR S
A
IN INTEREST, AGREES TO INDEMNIFY, DEFEND'AND HOLD HARMLESS THE CITY OF
LANDSCAPING
EDMONDS, WASHINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
FEE
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT 113 E
PLAN CHECK DEPOSIT
RQCELI?T
2
FROM THE ISSUANCE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REObIREMENTOF'ANY CITY ORDINANCE ,
-
1
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.�
TOTAL AMOUNT DUE
I REC2��
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
IS CORRECT., AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
APPLICATION APPROVAL
by
GIVEN
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
CALL
This application is not a permit until signed the
Building Official or his/her Deputy: and Fees are paid. and
TION;
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt is acknowledged in space provided.
WORKMEN'S C��SATION INSURANCE AND RCW 18.27.
F, ' - DATE
OFF141ALS SIGNATURE
SIG kTUR R AGENT)
DATE PIGN�D
"OWNER
771 -0220
sT,
S —15ATE,
REL6 ED:r
ATTENTION-/
EXTP33
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
411VI 141/ rif 111LIV f I f '4 �,f,
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CE RTIFI-
ORIGINAL -FILE rE��I!OW - INSWCTOA
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION t09
FAX
PINK - OWNER ASSESSOR
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