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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNEEMCE.NAME OF BUSINESS
MAILING ADDRESS
CITY ZIP TELEPHONE
NAME
[PPIERM�ITEXPIRE�S�
KUSE PERMIT
Z014E NUMBER aools-5
a SUITVAPT�
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PLAT NAMEISUBDIV$SIGN NO, LOT No LID NO
LI. FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED-
IM.Mk Rkld
REOUIREDDED;CATION— FT — -d
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METER SIZE LINE SIZE NO. OF FIXTURES PRY REQUIRED
YES C3 NO Ll
�EMARKS
9 FOR EROSION CONTROUDRAINAGS
9
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ENGINEERING
REVIEWEDiDATE
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REVIEWED BY
DATE
ELEPHONE
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OSTED
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NEW 1p RESIDENTIAL PLUMBING I EC.
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NUMBER NUMBER OF RITICAl
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REMARKS
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VALUATION
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATQ PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
,E
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DOMAIN .�RZS, E EWALKS, DRIVEWAYS. MARQUESS. ETC.) WILL REQUIRE
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SEPARATE PERMISSION.
afffil SURCHARGE
P MIT APPLICATION: ISO DAYS
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PERMIT LIMIT'. I YEAR PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORM (ON
'LI ORHE A�-IDNS AND SUCCSSORS
AP ' �ANT ON BE ED'"' R '�O.U.SE�IqH�E'H. THE CITY OF
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ENG. INSPECTION FEE
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ALLCLAIMS FOR DAMAGES OF WHATEVER NATURE,ARISING DIR ECTLY OR INDIRECTLY
RECEIPT
F N S PERMIT SHALL NOT BE
ROM THE ISSUA CE OF THIS PERMIT. ISSUANCE OF THI
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PIN CHECK DEPOSIT
0 EEMED To MODIFY, WAIVE OR REDUCE ANY REQUIREMENTOF ANY CITY ORDINA
I D VISION"
ANY ORDINANCE P OVISION'
RECEIP
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0 NORLIMI INANYWAYTHECITY-SABILI 0 ENFORCE
TOTAL AMOUNT DUE
THAT THEINF RMATION
APPLICATION APPROVAL
I HEREBY ACKNOWLEDGE THAT; HAVE READ THIS APPTICEAT'OLNY
GIVEN IS CORRECT. AND THAT AMTHEOWNE OR DU AUTHORI EDAGENTOF
THE OWNER. I AGREE TO COMPLY WITH CITY AN6 STATE LAWS REGUI-ATING CONSTRUC-
ED
CALL
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TION. AND IN DOING THE WCRKAUT RIZED THEREBY. NO PERSON WILL 89 Elll-lYT
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FOR INSPECTION
IN OLATiON OF THE LABOR CODE OF THE STATE OF WASHINGTON
VI
WORKMSNSCOMPENSATIO INSURANCE AND RCW 18.27.
S SIGNATURE DATE
OATS SIGNED
(425)
SIGN-UIEIOWNI"IRIOENTI
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771-0220
ASE..Y
F-XT 333
ATTE01ON
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTI,_ 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIF
ORIGINAL- FILE YELLOW - IMSPECTO
ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
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CITY OF EDMONDS
NUMBER
CONSTRUCTION PERMIT APPLICATION SUITEIAPTO
OWN AME OF BUSINESS
PUT NAMEISUBDIVISION NO LOT NO. LID NO.
LID FEE S
C MAILING ADDRESS
1ES11 11,111.1
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP 0
TELEPHONE
EXfS ING — PROPOSED — s._
CITY ZIP
Cj
i9
REOUIReDDEDICATION— PT — 1� M
METER SIZE LINE SIZE NO. OF 51XTURES PRV REOUIRED
NAME
YES 0 NO 0
L ADDRESS
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ZIP TELEPHONE
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DATE
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VARIANCE OR GO SHORELINE OR ADBII INSPEC
STATE LICENSE NUMBER
REOTION OSTED
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SERA REVIEW —SIGN AREA HEIGHT
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EXEMPT ALLOWED PR POSED ALLOWED PROPOSED
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NUMBER NUMBER OF
CIAL INSPECTOR AREA OCCUPANT
LOAD
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OWELLING
OF UNITS
RE QUIRED [] YES
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PRO GFIESS INSPECTIONS PER UBC 1031FINAL INSPECTION
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VALUATION FEE
PLAN CHECK FEE
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E T OURCE
BUILDING
IT!
PLAN CHECK NO:
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE W ORK NOT D. THIS PERMIT COVERS WORK TO
R
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONST UCTION ON THE PUBLIC
GRADlNG/FILL
DOMAIN (CURDS. SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PEV_�ISSION_
SURCHARGE
PEWMIT AFPLIcAT7ioW.'1 So DAYS--
PERMIT LIMIT, I YEAR -PROVIDED ORKISSTARTE.W ITHIN 160 DAIS
ENO, REVIEW FEES
SEE BACK OF PINK PERMiWT Pon MORE INFORMATION
-APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
INTEREST. AGREES TO 11,10EMNI Fy. DEFEND AND HOLD HARMLESS THE CITY OF
ENG. INSPECTION FEE
LANDSCAPING
IN
EDMONI)S,WASHING70N. ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANYA.D
INSPECTION F E
A LCLAIMS FOR DAMAGESOF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
L
RECEIPT
FROM THE I ANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
SEL
F ANY CITY ORDINANCE
PLAN CHECK DEPOSIT
DEEMED TO MODIFYr�yWTAHJE.E OR REDUCE ANY REQUIREMENT
0 ORDINANCE PROVISION.-
ECEIP -77
TOTAL AMOUNT DUE
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INF RMATION
APPLICATION APPROVAL
GIVEN S CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHOR 2ED AGENT 01
Th,� IPPI—t— '� 1-1 � 0-1111,1,j ,glld by Iho
THEOVYNER I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CON$TRUC-
BE
CALL Bb 0_ Offi—I .1 h111 D.P,�Iy n.d F .. ... P.-d
TIO�, AND IN 00 NO THE WORK AUTHORIZED THERE.Y. No PERSON WILL EMPLOYED
WASHINGTON RE ATING TO
-1 p, d1d.
FOR INSPECTION
IN VIOLATION OIF THE LABOR CODE OF THE STATB OF
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.21
0 1 S SIGNATURE DA E
OR AGENT) DATE SFIJEC
(425)
.(a
=NER
L.. 0_� ,
771-0220, RVL ASED BY D
EXT 333
A17ENTION
L
ITISUNLAWFU TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
FINAL I Ns ECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
P
ORIGINAL FILE YELLOW - INSPECTOR
A
HAS BEEN GRANTED. USC SECTION 109
PINK -OWNER GOLD ASSESSOR
FAX
DATE OF OCCUPANCY