20000864.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PERMIT EXPIRES
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PERMIT
NUMBER
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SUJTIUAPT�
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P�T NAMEISUBDIVISION NO.
LOT NO,
tD NO.
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LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL
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#-VARIANCE OR CU I SHORELINE OR ADS# I INSPECTION I BOND
SEPA REVIEW
COMPLETE EXEMPT
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HEIGHT
ALLOWED PROPOSED
OUNT RCELNG.
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LOT C VERAGE
UIRSO SETBACKS (FTJ PROPOSED SETBACKS (M.
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FRONT SIDE REAR FRONT UPSIDE REAR
0 ADDITION
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CHANGE OF USE
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0 GRADING CYGE
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REMARKS
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LAN CHECK NO: IVESTED DATE
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MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
E P U B LI C
BE DON E ON PA IVAT E ! R=TYRD NELWY.AA NY CAoRNQSUEU CT 10 N 0 N TH
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GRADINGIFILL
IV
DOMAIN (CURBS. SIDE SEPARATE PERMISSION.
T CHARGE
PERMIT APPLICATION:,,180 DAYS
PERMIT LIMIT., I YEAR ' PROVIDEDWORK STARTEOWITHIN 1800AYS
ENG� IEWIEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT� ON BEHALF o F HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCE$OFS
THE CITY F
ENG. INSPECTION FEE
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IN INTEREST. AGREETSoTNO INDEMN,,y o AYN.HOLD HARMLESS
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M"NDSjWA1'H"GA.Eii.1W�ATEVER NATURE, ARISING DIRECTLY OR IND.—-
ALLCLAI. 11RDAM
RECEIPT
FROM THE ISSUANCE OF EFMR`, SUANCE OF THIS PERMIT SHALL NOT BE
THIS P IS
PLAN CHECK DEPOSIT
q DEEMEDTO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANYCITY ORDINANCE
)RDINANCE PROVISION -
-
REC P
TOTAL AMOUNT DUE
- -
THAT' HAVE READ THIS APPLICATION� THAT THE INFORMATION
APPLICATION APPROVAL
I HEREBY ACKNOWLEDGE
GIVEN 15 CORRECT. AND THAT I AM THE OWIER6 DUJ.y AUTHORIZED AGENT 01
FE.ULATNg CoNSTRUC
Thl, IPPI-11- '� - . .-1 11 ��q t,' -
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BoTRATHE
THE OWNER. I AGREE TO COMPLY WITH CITY 0 LAW
TION; AND IN 0 IN HE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
o G TO
CALL su"J,, h,� D.P.1v p
. OR INSPECTION ,J �� uk101-� 11-1d.d,
WASH'N
DLAT ON OF THE LABOR CODE OF THE STATE OF GTON RELATING
IN V, I
F
DATE
WORKMENSCOMPENS I INSURANCE AND RCW 18.27.
WCtALS SIGNATURE
ADEN TD-ATE SIGNED
(425)
771-0220
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EXT1333
UNLAWFULTO USE OR OCCU1YA.UILDING OR STRUCTURE UNTIL
771-0221
IT IS
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE YELLOW � INSPECTOR
A FINAL
BEEN GRANTED. UBC SECTION 109
FAX
PINK -OWNER GOLD -ASSESSOR
CATE OF OCCUPANCY HAS
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS ....................
FOUNDATION:
Footing ......................
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Pier/Porch .................
Retaining Wall ...........
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Stab Insulation ..........
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PLUMBING:
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EXTERIOR SHEATHING
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Ceiling Insulation
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SHEETROCK NAILING
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SPECIAL INSPECTION
MISCELLANEOUS
FINAL APPROVAL FOR
4- -R� I
OCCUPANCY ..............
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CONSTRUCTION PERMIT APPLICATION JOB SU TEIAPTH
ADDRESS
OWNER NAMEINAME 0 BUS NESS PLAT NAMEISUBDIVISION NO. LIO NO.
WgAkew LID FEE $
MAILING ADDRESS TESCP A"p 0
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP SW P_lt R"" 0
S� 0
0
EXISTING— PROPOSED—
CIT�ZIP —PHONE
REQUIRED DEDICATION —
METER SFZE LINE SIZE NO. OF FIXTURES FIRM REQUIRED
NAME YES 0 NO 0
EMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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CITY ZIP TELEPHONE
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ENGINEERING REVIEWEDIDATE
ADDRESS
DATE
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REVIEWED By
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RE 0 POSTED
RE 0
�E NO
STATE LICENSE NUMBER N DATE CHECKEDBY YES ONO
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ACCOUNT PARCEL NO*
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- LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOS D ETBACKS(FT.)
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
TH FUZES C
I Sp E. IT A U 0
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC GRADINGIFILL
Go E ON -VATE F'
P. ALKS,DRRVEWAY MARQUEES, ETC.) WILL REQUIRE
B1 DOMAIN (CURES. SIDEW S
AIN U. S - '
SEPARATE PERM ISSIOM
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-
R L'CATION. "'I"AYS
T APR
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AR - WOBKIrSTARTEBWIlHIN 180.AYS ENG, IEW FEES
..IT LIMIT ' YEAR -
IT '. "OFE 'N'OF.
SEE SACK OF P K EF. R ATION
SEE BACK OF
*A�PLIOANT ON 11HALFOF HIS OR HEIIIPOUIE, IIEIRI* ASSIGNS AND SU11111 I END, INSPECTION F E
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P
A DEPEND AND HOLD HARMLESS THE CITY OF
IN INT'R:S.lAQRl.ETl.T�O NGEMN.1,Y I-AND-CAPIN
IN INTEREST AGREED To,
:T AGENTS FRO M ANY AND
.. INSPECTION FEE
MON LS. EMPLOYEES. AND
EDMOND. WASHINGTON I
ED . SHIN �
ON
ALLCLAIMSFOR DAMAGESOFWHATEVER NATURE,ARISING DIRECTLY INDIRECTLY RECEIPT
LL.". AMA.E.�
BE
x FROM THE ISSUANCE OF THIS PERMIT, ISS ANCE OF THIS PERMIT SHALL NOT PLAN CHECK DEPOSIT
CE F,
9 .E.E. To MODIFY . WAIVE REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Y. WA'VE 0
SEMED To Moot Y WAIVE 0
DOS ENFORCE ANY ORDINANCE PROVISION,' RED P
0 N LIMIT IN ANY WAY THE CITY'S ABILITY TO
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE REAQTHIl APPLICATION! THAT THE INFORMATION APPLICATION APPRO�tL
GIVEN IS CORRECT, AND THAT I AM THE OWNER, On THE DULY AUTHORIZED AGENT OF T "' -n " ' pa"NI ur"I ' gn
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THE NER I AGREE To COMPI Y WITH CITY AND STATE LAWS REGULATIN CALL dim Olpl"I"'ll
OW G CONSTRUC� B.il
TION;ANIIND ING THE WORK MITHORIEDTI-15RESY, NO PERSON WILL BE EMPLOYED
OF WASHINGTON RELATING TO
0 FOR INSPECTION
IN ON OF THE LABOR CODE OF THE STATE
VIOLATI DATE
W.FK.EN'K C2PENSATION INSURANCE AND RUIV IIL27. 0 I -AL. I ATURE
_
I
DATE SIGNED (425) " I
771-0220 -I.A�EDEIY DATE
ATTENI%N EXTP33
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
A FINAL NSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL - FILE fl ULOW -,INSPECTO
COL A
CATE OFIOCCUPANCY HAS BEEN GRANTED. USC SECTION 109 FAX PINK - OWNER
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