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SEPARATE PERMISSION.
STATE SURCHARGE
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT.1 YEAR- PROVIDED WORK IS STARTEOWITHIN 100 DAYS
ENG, REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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ORDINANCE PROVISION:
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Y NOR UMITIN ANYWAYTHE CITY 'S ABILITY TO ENFORCE ANY
TOTAL AMOUNT DUE
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I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION APPROVAL
I HEREBY ACKNOWLEDGE THAT
GIVEN IS CORRECT. AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
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TION: AND IN DOING THE. WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEMAME OF BUSINESS
ADDRESS
CITY
NAME
ADDRESS
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PERMIT EXPIRES 11
ZOE PERMIT
oNE j NUMBER
JOB SUITE/APT#
ADORES -
•—
PLAT NAME/SUBDIVISION NO.
LID NO.
JTOTNO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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EXISTING PROPOSED —
REQUIRED DEDICATION FT
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METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
V
ES NO Q
REMARKS
OWNF_RICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
FIRE REVIEWED BY
ZIP TELEPHONE
DATE
STATE LICENSE NUMBER / II ,, EXPIPATI NDATE
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CHECKED BY
-
REO'D
QYE5 QIG
POSTED
SERA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED.
PROPERTY TAX ACCOUNT PARCEL NO.
E%P I
❑ NEW Gee. ❑ PLUMSINGIMECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (IT,)
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PROPOSED SETBACKS (FT)
FRONT UPSIDE REAR
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❑ AUDITION ❑ COMMERCIAL ❑ CHANGED USE
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PARKING
LOT AREA
PLANNING REVIEWED BY DATE
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REO'D PROVIDED
❑ ❑ GRADING CYDS ❑ (FENCE X _ FT) REPAIREMARKS
❑ DEMOLISH S` TANK ❑ OTHER
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REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D
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VALUATION
FEE
HEAT SOURCE GLAZING % LOT SLOPE 1
rMECHANICAL
PLAN CHECK NO: VEBTBD DATE
• THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
E DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
GRADINGIFILL
SEPARATE PERMISSION.
STATE SURCHARGE
PERMIT APPLICATION: 188 DAYS
PERMIT LIMIT: t PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENO, REVIEW FEES
SEE BACKCK OF OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORSNINTEREST.
v `�
w AGREES DEFEND AND HOLD HARMLESS THE CITY
EREDUCE
LANDSCA NG )
i EDMONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
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ANY REQUIREMENTO ANY CITY ORDINANCEMNIFY,
DEEMED TO MODIFY, WAIVEORTO
SHALL NOT BE
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CHECK DE'
DEPOSIT
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O NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.—
OR(
RECEIPT
i
TOTAL AMOUNT DUE
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 oppllcalian Is not a Do 4 until aa;-d by Ino
THEOWNER. I AGREE TC COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
CALL
Builtlinp 011iciel or hislher Deputy: antl Fees aro paltl. antl
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
FOR 1NSPECTION rocoipl is anknowtotlgo4In spew provitleC.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
FICIALS SIGNA DATE
DATE BIG ED
(425)
SIGNATURE (OWNER OR AGENT)
r I�
1 I '�.. �• i.
': 7!'yy1-0220
LEASED BY D TE
ATTENTION
EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL -FILE YELLOW- INSPECTOR
A FINAL
- CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
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