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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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NAME
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CITY
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STATE LICENSE NUMBER 4 DATE
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pROPERTY TAX ACCOUNT PARCEL NO.
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NEW L PLUMBING I MECH
COMPLIANCE OR
ADDITION CHANGE OF USE
REMODEL C] SIGN
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REPAIR GRADING CYDS cl ( X FT)
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liaG CA A E FETAININYI WALL 0 RENEWAL
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t�IUMSER NUMBER.'
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PERMIT EXPIRES
USE PERMIT
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NUMBER
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ADDRESS
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PI -AT NAMEOSUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHTOFWAYP R OFFICIAL STREET MAP
P e,s RNe-d
St
EXISTING — PROPOSED—
S-W_
..IN R-4-isd
REQUIRED DEDICATION— FT —
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METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 0 NO 0
RESPONSIBLE FOR
FIRE REVIEWED BY DATE
VARIANCE OR CU SHORELINE OR ADBN INIPEOTION I BOND
REO'D POSTED
0 YES 0 NO
I SEPA REVIEW SIGN AREA HEIGHT
COMPLETE I EXEMPT ALLOWED I PROPOSED ALLOWED PROPOSED
XP I
LOT COVERAGE , REQUIRED SETBACKS (FT) PROPOSED SETBACKS FT'
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
I
LOT AREA I PLANNING
PARKING REVIEWED By DATE
REO'D I PROVIDED
CHECKED By
LOAD I
.�ITI..S PER LIBC I 01111FINAL INSPECTION REO'Dl
22-(6c- ,ND DrFic-4 -rot, 2-2—'
VALUATION I FEE
PLAN CHECK FEE
LA 'NV Ti
LOT SLOPE I
BUILDING
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7
PLAN CHECK NO:
JSTED DATE
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THISVERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADINGIFILL
.DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
I SEPARATE PERMISSION.
STATE SURCHARGE
PERMIT APPLICATION: 180 DAYS
P K I WITHIN 180 DAYS
PERMIT LIMIT.- I YEAR - ROVIDEDWOR SSTARTED
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
No
IN ITNEFIISIWT.AAGRI.ITS.T.0 N FY, DEFE AND THE CITY Lu
�T�GEMFF�'('AALS, FROM ANY AND
LANDSCAPING
EDMO EMPLOYEES, AN AGENTS
ALLCLAIMS FOR DAMAGES OFWHATEVER NATUR5,ARISINUDIRECTLYORiNDIRECTLY
INSPECTION FEE
RECEIPT
X
FR NA THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
DEEMEDT MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0
NOR LIMIT IN ANY WAYTHS CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
TOTAL AMOUNT DUE IF
OFT
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE IN FORMATION
APPLICATION
APP =AE
GIVEN 11 ClIFIC, . AND THAT, A. THE OWNER. OR THE DULY AUTHORIZED AGENT OF
Tl" ,u,N,ou is .-N, usifil ip.0 by the
THEO..ER 'A.NEET.C.MLY�iTN CITY AND STATE LAWS REGULATING CONSTAUC-
CALL
Sis' di�g "KIM , his,lill Deputy: end Fees — piud. ,d
TION; A%IN DOING THE WORK AUTHORIZED TH EAEOY, NO P 5RSON WILL BE LEMPLOY ED
I N 4 'ON OF T 01 WASHINGTON RE AT,NG TO
FOR INdPECTION
1pt 1. ,k,,wi,dg,d 1, sp— pr.vided.
ODE OF THE S-1
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MENS C044TA —NCE AND RCW 10.27.
OFF!CIAL�JXIN RE DATE
SIG 0
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DAT S113NID
(425)
f _
1-0220
771—RELIEASED
BY
A-rTENTIOW
EXT 333
IT 1� UNLAWFUL TOV. 08 OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A . IS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE - YELLO INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - OWNER - COLD - ASSESSOR
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