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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEMAME OF BUSINESS
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MAILING ADDRESS
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USE PERMIT �, �9
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REMARKS
eonraacs INSPPCTIONS PER UBC 1081FINAL INSPECTION RE'
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADING/FILL
DOMAIN ICURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
STATE SURCHARGE
¢ PER MITAPPLICATION: 180DAYS
50'
PERMIT LIMIT: 1 YEAR, WORK IS STARTED WITHIN 100 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION.
'o 'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
ANY AND
ENG. INSPECTION FEE
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f EDMONDS, WASNINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM
ALL CLAIMS PoRDAMAGES OF WHATEVER NATUPE.ARISING DIRECTLYORINOIRECTLY
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RECEIPT ���,
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
DEEMEDTO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OFANY CITYOROINANCE
ANY ORDINANCE PROVISION.'
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i NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE
TOTAL AMOUNT DUE
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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
Thls aPPI-1.1 in not a 1-1- until xipnpa by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
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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 INSPECTION rpcpipl is pcknowlptlBOtl in spnco plpvitlp0.
WORKMEN'S COMPENSATION INSURANCE AND FCW 18,21.
OFF IALS SIGNATURE DATE
SIGN TUR (01WNERORAG T DATE SIGNE
(425)
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771-0220
RELEASED BY DATE
EXT 333
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL. FILE vELtow INSP croR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
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RE -INSPECTED OUTSTANDING ISSUES- GRANT FINAL PROJECT APPROVAL
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CITY OF EDMONDS `Z �, 1.L NUMBER
CONSTRUCTION PERMIT APPLICATION JOB BDITEIAPTk
ADDRESS � i�Jti! - OL` �/ /i/� �
OWNER NAMEMAMEOF BUSINESS c,(J O.
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w MAILING ADDRESS (' eC ^� LID FEES
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REQUIRED SETBACKS (FL)
PROPOSED SETBACKS (FT.)
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LOT
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT VRSIDE REAR
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COMMERCIAL COMPLIANCE OR
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LOAD- tom!
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UNITS f NUMBER / i
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DESCRIBE WORK TO BE DONE
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REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
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PLA(`I,ICHE�Cf NO: VESTED GATE
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
-- -"
GRADING/FILL
LL REQUIRE
= DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL..
SEPARATE PERMISSION.
STATE SURCHARGE
( PERMITAPPLICATION: 180 DAYS
j4 PERMIT LIMIT.1 YEAR • PROVIDED WORK IS STARTED WITHIN 180 DAYS
o.
ENG REVIEW FEES
SEE BACK OF PINK PERMIT FOR MOPE INFORMATION
ENG. INSPECTION FEE '.-
5
H •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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Sm
EOMONDS, WASHMGTON, ITS OFFICIALS, EMPLOYEES, AND AD ANY
ALLCLAIMS FOR DAMAGES OFWHATEVER NATURE, ARISING DIRECTLYORINDIRECTLY
INSEEGUQNibE
RECEIPT
_
THE ISSUANCE Of THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
OF ANY CITY ORDINANCEj�
PLAN CHECK DEPOSIT f C-' 30Z
j DEEMED TO MODIFY, WAIVE OR SEDUCE ANY REQUIREMENT
DEEM
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.RECEI
•G^� e�r�1
s
NT DUE I f} f ,
/��
! I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATIONAPPLICATION
APPROVAL
GIVEN IS CORRECT; AND THAT 1 AM THE OWNER, OR THE DULY AUTHORIZED AGENTOFDThis
OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUCLL
application is not a ppemTHE
Builtlinp 011icial or hislharTION;ANDINDOINGTHEWORKAUTHORIZEDTHERFBY,NOPERSONWILLBEEMPLOYED
OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
AND RCW 18.2].
rpcoipt is acMnowlod0odinspac_provitlotl.
PECTIONINVIOLATION
:/'�
WORKMEN'S COMPENSATIONINSURANCE
��� .COFFI IALS SIGNATURDATE/„
�I-�
(425iO�O
DATE Si;GNEQ
G J 11JJ//
`t
RELEASED BY ) DATE
ATTENTION
EXT 333
--'�'
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771'0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE YELLOW ,, INSP
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX PINK -OWNER GOLD-ASSESSOR-
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