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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PERMIT EXPIRES *
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LID FEE S
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EXIS ING — PROPOSED—
0
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METERSIZE
LINE SIZE
NO OF FIXTURES
PRV REQUIRED
YES 0 NO 0
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLJDRAINAGE I.
CITY ZIP
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L�N.IN.ERIN.
REVIEWED/DATE
ADDRESS
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FIRE REVIEWED BY
DATE
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INSPECTION
rSTATE LICENSE NUMBER
IANCE 08 CU
VARIANCE 08 CU
SHORELINE 08 ADBK PIOND
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SEPAREVIEW
FALLOWED
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AR
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REMARKS
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PLAN CHECK NO: VE TED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
2 DOMAIN (CUASS, SIDEWALKS. DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
3 SEPARATE PERMISSION.
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2
P MIT APPLICATION: 180 DAYS
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PERMIT LIMIT.� I YEAR - PROVIDED OAK IS STARTED WITHIN UJO DAYS
SEE SACK OF PINK PERMIT FOR MORE INFORMATION
;APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
N NTEREST� AGREES To �NDEMNWY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, TSOFFlCIALS, EMPLOYEES. AND A 'ENTS FROM ANY AND
A LOLAIM11OR 'AMAOESOF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
L ION TNES�U ' CE OF T T BE
IF AN WAIV HIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NO C,
REDUCEANY REQUIREMENTOF -YCITYOSOINAN
DEEMEDTOMODIFY. EOR
C NORLIMITINANYWAYTHE CITY'SABILITY To ENFORCE ANY ORD—,Y— --l.—I.
CCUPANT
SPECIAL INSPECTOR JAREA 'LOAD
REQUIRED 0 YEE
REMARKS
PROGRESS INSPECTIONS PER USC, 108/FINAL INSPECTION REO'D Z
VALUATION
FEE
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
GRADINGIFILL
STATE SURCHARGE
ENG. REVIEW FEES
LANDSCAP N
MSPECTION FEE
PLAN CHECK DEPOSIT
RECEIPT
TOTAL AMOUNT OU
REC W
1 HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION� THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT. AND TH T I AM THE OWNER R THE OULY A THORIZED AGENT OF
OSTATE
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LAWS REU
A LATING CONSTRUC-
THE OWNER, I AGREE TO COMPLY WITH CITY AN6
CALL
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TION� AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
OF WASHINGTON RELATING TO
FOR INSPEC TION
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IN VIOLATION OF THE LABOR CODE OF THE STATE
16.21.
DATE
WORKMEN'S COMPENSATION INSURANCE AND RCW
—
(425)
FICIALS SIG��
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SiGNATURE4&�I�
DATE SIGNED
771-0220
DATF
21
RE ASEDBY
ATTENTION
EXT1333
IT I$ UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTWI�
ORIGiNAL-FILE . YELLOW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - OWNER - GOLD - ASSESSOR
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RECORD OF INSPECTIONS�_
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing......................
wall......................
Pier/Porch .................
6,
Retaining Wall ...........
Stab Insulation ..........
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Gas Piping ..............
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INSULATION ..............
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SPECIAL INSPECTION
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MISCELLANEOUS
FINAL APPROVAL FOR
OCCUPANCY ..........
DATE E VED
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rr PERMIT EXPIRES
PERM T
CITY OF EDMONDS S- (o NUMBER,-?,= LonL-_
JOB SUITEIAPT.
CONSTRUCTION PERMIT APPLICATION ADDIEll
OWIEFINA "AME01111SIN D LOT NO. LID NO.
PLAT NAMEISUB IVISION NO,
v, I I I r--, LID FEE S
MAILING ADDRESS F WAY PER OFFICIAL STREET MAP TESCP App—d ss 0
Ass, 0
cm
wk A."I'2' 0
CITY EXISTING PROPOSED— d 0
REQUIRED DEDICATION— FT
P_ PIQUIR10
TURES is
NAME YES 0 NO 0
ADDRESS REMARKS E
OWNE
CITY ZIP
11ELEPHONE
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ENGINEERING R5VIEWEDMATE
ADDRESS
FIRE REVIEWED BY DATE
CITY ZIP TELEPHONE
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VARIANCE OR CU SHORELINE OR ADS#
—
STATE LICENSE NUMBE E
A01,00 BY
0
f 0( —SlaNAR5A HEIGHT
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COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED
TAX ACCOUNT PARCEL NO.
P13OPERTY
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LOT COVERAGE REQUIRED SETBACK$ (Fr.) PROPOSED SET ACKS CFT)
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8 RE []YES
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DESCRIBE WORK TO BE DONE
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REMARKS
PROGRESS INSPECTIONS PER UBC 1081FINAL INSPECTION REO'D
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0
E ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC GRADINGIFILL
WAY
(CURDS SIDEWALKS. DRIVE S. MA QUEES, ETC.), WILL REOUIRE
:1 SEPARATE PERMISSION.
STATE SURCHARGE
PE MIT APPLICATIONt 180 DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS ONG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Is PLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNSAND SUCCESORS
OF
C,
;A LANDSCAMN
N INTEREST. AGREES TO IMNIFY, DEFEND AND HOLD HARML SS THE CITY
:NO
EMPLOYEES, AND AGENTS FROM ANY AND INSPECTION FEE
2 E IONDS.WASHINGTO TS 0 FICIALS,
0
N�OFWHATEVER NAMTURE, ZOING DIRECTLYOR INDIRECTLY
ALLCLAIMSFORDA AGE
RECEIPT
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE PLAN CHECK DEPOSIT
ANY CITY ORDINANCE
IDEEMED To MODIFY, WAIVE OR FIE CE ANY REOURREMENTOF
CITY'S ADBILITY TO ENFORCE ANY ORDINANCE PROVISION.'
0 NOR LIMIT INANYWAYTHE
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT: HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT. AND TH T AM THE OWNER 0TRATHEOULYA THORIZEDAGENTOF
CITY AN6 AWS REGULATING CONSTSUC-
A S EL CALL
Th,, ppl—li- is n,Q , pij bmfit llg.od by th,
F111 ,, osid, ,d
THE OWNER. I AGREE TO COMPLY WITH
11OW AN" IN DOINIS THE A.UTH.1111ED THIFE13Y� NO PERSON WILL BE EMPLOYED FOR INSPECTION
TO
011,1 0, hjA,Fs, Dap,ty: ,d
o,,,pt 1, ,k,m$,dgod 11 sp— pmid,d.
.L .N THE L=, RELATING
IN V) AT OF _ E OF THE STATE OF WASHINGTON
WORKMEW&COMPENSATION INSURANCE AND RCW 18,27.
(425)DATE SIGNED
RCIALS SIGNAT DATE
771-0220 RE
ATTENTION OR STRUCTURE UNTIL EXT1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING 771-0221
A FINAL NSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL PILE YELLOW � INSPECTOR
CATE OFOCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX PINK - OWNER GOLD - ASSESSOR
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