20000734.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
IES N�MEINAME OF BUSINESS
CITY . ZIP
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NAME
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PERMIT
NUMBER
JOB SUITEIAPT.
ADDRESS
PLAT NAMEJSUBDIVISION NO, LOT NO. L16 NO,
11. FEE S
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP R
P.— A.JA
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REOUIREDDEDIIATION_ FT
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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
DOMAIN (CURB%SIDEWALKS. DRIVE AYS, MARQUEES, ETC) WILL REQUIRE
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SEPARATE PERMISSIOM
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT. 1 YEAR * PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT OR MORE INFORMATION
-APPLICANT, ON BEHALF 0 HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCSSORS
IN INTEREST. AGREES TO NDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
TS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
'OMONDi"A G ON FWHATEVER NATURE� ARISING DIRECTLY OR INDIRECTLY
ALL"" F='-""�'NNAO'�ETA-ftll PERMIT IE�UANCE OF THIS PERMIT SHALL NOT BE
FROM TH" OF TH F
DEE.EDTC, AIVE OR REDUCE ANY AEOUIREMENT 0 ANY CITY ORDINANCE
1 NOR LIMIT IN ANY V�YTHE CITYS ABILITY TO ENFORCE ANY ORDIN-1.
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ROGRESS INSPECTIONS PER UBC 1081FINAL INSPECTION REO-DIE.
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VALUATION
FEE
PLAN CHECK FEE
BUILDING
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GRADINGIFILIL
STATE SURCHARGE
ENG. REVIEW FEES
LANDSCAPING
INSPECTION FEE
PLAN CHECK DEPOSIT
TOTAL AMOUNT UE
IHERE Y ACKNOWLEDGE THAT I HAVE SFOAWDTH,�S APPLICATIUN. THAT T.I N1 F-A`R.N
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APPLICATION APPROVAL
IS NE OR TH D Y AUTH SIZED AGENT OF
GIVEN CORRECT, AND THAT I AM THE OISTIU
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0 CIALS SIGN DATE
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(425)
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SIGNATURE (OW(rR
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771-0220
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IT IS UNLAWFUL TO USE
OR OCCUPY A BUILDI NG OR STRUCTURE UNTIL
771-0221
AND APPROVAL OR A CERTIFI-
1 ORIGINA17- FILE - YELLOW - INSPECTOI
A FINAL INSPECTION HAS BEEN MADE
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
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approval ofthe described work
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AILED FINAL INSPECTION - OUTSTANDING ISSUES
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—RE-INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
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CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB SUITUAPTO
ADDRESS
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OWNER NA.MEINAME OF BUSINESS /ASke- LID NO.
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METER SIZE I LINE SIZE I 10,01FIXTUREI PRY REQUIRED
NAME YES 0 NO 0
REMARKS
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CITY 71HONI
NAME
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It ADDRESS
DATE
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STATE LICENSE NUM ER ON.
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ALLOWED PROPOSED.
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QUIREO SETBACKS PROPOSED SETBACKS (FT.)
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NUMBER OF
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REMARKS
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VALUATION
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THIS PERMIT AUTHORIZES ONLY THE W06k NOTED. THIS PERMIT COVERS WORK TO
�j BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC GRADING/Fftl
WILL REQUIRE
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,I
SEPARATE PERMISSION,
STATE SURCHARGE
PERNA 4LICATION: ISODAYS '
IS 80 DAYS I,
PERMIT LIMIT�. I YEAR - PROVIDED WORK STARTED WITHIN I ENG. REVIEW FEES
SEE SACK OF PINK PERMIT 'OR MORE INFORMATION FEE
-APP.CA.1 ON BEHALF OF IS OR HER SPOUSE. HEIRS, ASSI.NE AND SUCCESOAS
AND HOLD HARMLESS THE CITY OF LANDSCAPIN
IN INT REST, AGREES TO INDEMNIFY. DEFEND
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EOMON.S. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND INSPECTION FEE
A LLCLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECIL,
THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE PLAN CHECK DEPOSIT
FROM
DEEMED To MODIFY, WAIVE OR REDUCE ANY REQUIREMENT 11 ANY CITY ORDIll"Cl
TO ENFORCE ANY ORD1 96"lal — -----------
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY
TOTAL AMOUNT DUE
[HERE ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION I APPLICATION APPROVAL
By
ZED AD ENT 01 Th, IPP41-tl" �l '. , p,,,.l �Iij ,910d bY thl
GIVEN CORRECT. A D THAT I AM THE OWNER� OR THE DULY AUTHOF GCO STR CALL
NO CITY AND STATE LAW RSCtUI�IIN N Uc_ D11111:
THE OWNER. I AGREE COMPLY WITH Bulldmg Oth-I �l hi0h'
TION; AND IN DOING THE WORK AUTHORIZED THEREBY� NO PESSO WILL BE EMPLOYED .pI
NTON RELATING TO FOR INSPECTION
IN VIOLATION OF THE LA80R CODE OF THE STATE OF WASHING
WORKMEN'S COMPENSATION INSURANCE AND Rp 18,27. 0 ICIALS SIGNAT DATE
E SIGNED (425)
771-0220 __ RELEASED BY DATE
EXT 333
AJt A (1)
-
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-SPEDTOn'
PINK-OWNER GOLD -ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX