20000759.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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2 PERMIT APPLICATION: 180 DAYS
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ED M TO MODIFY W 'VE Q ANY CITY ORDINANCE
DEEMED To MODI Y, WAIVE OR REDUCE ANY REQUIREMENT 0
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PLAN CHECK DEPOSIT
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0 NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE Ally ORU-1-V N
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPILICATIC'N4, THAT THE IEN.IORMATION
N
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GIVEN I CORRECT� AND THAT I AM THE OWNER, OR THE 0 E
S
:AE
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THE OWNER, I AGREE To COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
EMPLOYED
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CALL
BE
TION�ANDIND IN THE WORK AUTHORIZED THEREBY, NO PERSON WILL DIE
0 G E GTON BE, TING To
THE LABOR CODE OF THE STAT OF WASHIN RELATING TO
IF IOR INSPECTIII
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IN OLAT ON OF
WORKMEWS INSURANCE AND HOW 18.27�
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771-0220
Wli, 1 1500
WeTENTION
ITIS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
OCCUPANT
GROUP r,?
rO—CCUPANT
ILOAD
INSPECTION
VALUATION I FEE
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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NAME
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CITY �____Zl _PP �TEIE 11-I.N �-
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JOB SUITEIAPTP
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PLAT NAMEISUBDJVISIOM NO.
LOT NO.
LOT NO.
LID NO.
LID NO -
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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0
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ExisrING_ PROPOSED—
0
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REQUIRED DEDICATION FT
METER SIZE
LINE SIZE
NO. OF FIXTURES
PAN, REQUIRE
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1 IREWIARK—TRA—A RESPONSIBLE FOR EROSION CONTROUGRAINAGE 151
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—of FIRE REVIEWED BY DATE
VARIANCE OR CU H REUNEORAOB. I INSPECTION BOND
EXPIRATION LAI t P".. .1 cl YREOID POSTED
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—StGNAREA HEIGHT
ALLOW. PROPOSED
�ARCEL NO. COMPLETE I EXEMPT ALLOWED I PROPOSED
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ALLOWED PROPOSED
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PARKING LOT AREA PUINNIOG REVIEWED By DATE
t& REMODEL
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0 SIGN
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0 REPAIR
GRADING OYDS
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0 DEMOLISH
TANK
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RENEWAL
USIN119 AOTIVI P LAIN:
NUMBER UMBER OF
OF DWELLING
STORIES UNITS
DESCRIBE WORK TO 85 DONE
CHECKEDBY JIYPEOICO RPION C I I'll
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SPECIAL INSPECTOR AREA 0 U AN
REQUIRED C] YES L D
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VALUATION I FEE
PLAN CHECK FEE
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PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES W RK NOTED HIS PERMIT COVERS WORK TO
Be DONE ON PRIVATE ONLY THE 00 Ly. ANY C�NTSTRUCTION ON THE SUC
EWAUKS,DRIVE AYS, MARQUEES, ETC.) WILL R
DOMAIN (CURBS, SID PROPERTY N EQUUIRE
SEPARATE PERMISSION.
GRADINGIFILL
STATE SURCHARGE
PERMIT APPUCATIOW 190 DAYS
EDW RK I
PERMIT LIMIT. I YEAR PROVID S STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ENG. REVIEW FEES
�A PLICANT, ON BEHALF SSIGNS AND SUCCESORS
P 01 HIS OR �IRSPOU.'E�NHDEIHROLDA
IN INTERE AGREES TO ' "' `Y EFEN HARMLESS THE CITY OF
2 EDMONCSST' HINGTON, �T�DIFICI�LS, EMPLOYEES, AND AGENTS FROM ANY AND
'WAS RIBINGOI
ALLCLAIMSFORDA AGESOFWHATEVER�NATURE�A RECTLYORINOIRECTLY
I
x FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERM T SHALL NOT 85
9 0 EMED TO MODIFY, WAIVE 08 REDUCE ANY REQUIREMENTOF ANY CITY ORDINANCE
0 NER LIMIT IN ANY WAYTHE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
LANOSCAPI G
INSPECTION FEE
PLAN CHECK DEPOSIT
RECEW
I HEREBY ACKNOWLEDGE THAT I HAVE REACTHIRS APPTL1,CEATIULNY THAT THE IN50RMATION
GIVEN IS CORRECT; AND THAT I AM THE NE 0, C AUTHORIZED AGENT OF
THE HER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC�
OW
G THE WORK AUTHORIZED THEFEBY� NO PERS N WILL BE EMPLOYED
TION , ANDIIN DOIN THE LABOR CODE OF THE STATE OF 0
IN VtOLAT ON OF WAS141NGTON RELATING TO
WORKMEN'S COMFENSAH0 INSURANCE AND RCW 18 11
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APPLICATION APPROVAL
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05 ;ALSBIGNATURE DATE
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- ']LEASED 8
771 0220
ATTENTION OR STRUCTURE UNTIL
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
EXT 333
771-0221
FAX
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