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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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LAN CHECK NO: 11111EIDIATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS ERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ON' ' ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.1 WILL 8 EQUIRE
:1 SEPARATE PERMISSION.
PERMITAPPLICATI N: 180DAYS
P
PERMIT LIMIT, 1 YEAR - ROVIDED WORK IS STARTED WITHIN 180DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
;APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
E ST, AGREES TO EMN15Y. DEFEND AND H TO HARMLESS THE CITY OF
N NT'2 PLOYEES. AND AGENTS FROM ANY AND
:NDEMN15Y.
M.NDE, WASHINGTON. TSOFFICIALS.E
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIR-1
F R S PERMIT. ISSUANCE OF THIS IEF.IT S.ALL NOT BE
0. THE ISSUANCE OF T.
DE EMED TO MODIFY. WMVE OR REDUCE ANY REQUIREMENT 0 ANY CITY ORDINANCE
NOR LIMIT IN ANYWAY THE CITY S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D 3.
.Regardless Of Whefief the water syst
is -open vi Closed, expansion tanks
rAqUired 'A bell
all water tan
VAL6`ATI
FEE
PLAN CHECK FEE
BUILDING
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MECHANICAL
GRADINGIFILL
URCHARGE
ENS, REVIEW FEES
ENO INSPECTION FEE
LANDSCAPING
INSPECTION FEE
PLAN CHECK DEPOSIT
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION. THAT THE INFORMATION
GIVEN IS CORRECT, AND THAT AM THE OWNER, OR THE OUll AUTHOHZED AGENT OF
�
THEOWNER [AGREETOCOMPLY WITH CITY AND STATE LAWS REGULAI ING CONSTRUC
CALL
TION, AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
R CODE 0 F THE STATE OF WASHINGTON RE LATING TO
FOR INSPECTII
IN VI N .1 B
W..OLATI NE INSURANCE AND RCW 18.27,
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-SIGNATU
DATE lIGNlD
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771-0220
EXTt333
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
A FINAL
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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RECORD OF INSPECTIONS
. ...... _77
INSPECTOR
DATE APPROVED
SETBACKS ......................
FOUNDATION:
Footing ......................
wall..........................
PierlPorch .................
Retaining Wall ...........
Slab Insulation ..........
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PLUMBING:
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MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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j�MP 7 -7 V`_
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
!JIR NAMEINAME 01 IUSINS
, bLoo, CaiRna
MAILINGADDRESS
1711115" Ave W
CITY
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NAME
ADDRESS
CITY ZIP TELEPHONE
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USE k
ZONE PERMIT
NUMBER 20 9
ADDRESS Avg bu 5U,TEIAPT,
PLAT NAMEISUBDIVISION NO, LOT NO. Li NO.
1 11. 'BE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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U.. " R."
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
LINE SIZE I MO. OF FIXTURES PRV P"QUIR D
YES I NO
RE
=AKlSTll I-PONSIALF FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWEDIDATE
AD FEES
FIRE REVIEWED BY DATE
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CITY
TELEPHON 14-3a
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INERPEEOC�ION
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STATE LICENSE NUMBER EXPI IATE CHECKEDBY
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COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED , PROPOSED
PROPERTYTAX ACCOUNT PARCEL NO.
EXP I
,
0 NEW [!(;E.ID'ENTIAL PLUMBING I MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS III
FRONT SIDE REAR
PROPOSED BET.A. SIT
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;EVIEWED BY DATE
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MARKS
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0 (TYPE OF USE. BUSIN EBB R ACTIVITY) EXPLAIN:
OCCUPANT
c 'NECKED B;PE
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NUMBER
NUMB ERO F
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AREAS,
S IAL 1;
-PANT
LOAD
OF
0 STOR ES
U.—
NUMSE
REOUIRED
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REMARKS
INSPECTION REQ
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g PROGRESS INSPECTIONS PER USIC 108/FINAL
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PLAN CHECK FEE
HEATSOURCE
LOT SLOPE I
BUILDING
PLAN CHECK NO:
VESTED DATE
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADINGIFILL
DOMAIN (CURBS. SIDEWALKS RIV9WAYS MAROUEES. ETC.) WILL REQUIRE
�SJAI�RURCHAAGE
ft�Q PEF14ISSION.
SE��D
OE6�11�APPLICATI N: ISO DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
S
ENG.REVIEWFEES
..,SEERACK OF, PINK PERMIT i�� ORE -----------
A PPL I IC . ANT, ON BEHALF OF HIS OR HER SPOUSE. HEIR ASSIG�SANDSUCCESORS
INSPECTION FEE
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOL D HARMLESS THE CITY OF
LANDSCAPING
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
INSPECTION FEE
'Q ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
PERMIT SHALL NOT BE
RECEIPT
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS
0 EMED TO MODIFY. WAIVE OR REDUCE ANY REOUIREMENT OF ANY CITY ORDINANCE
ORDINANCE PROVISION,'
PLAIN CHECK DEPOSIT
REG� PT
0 NEORLIMIT IN ANYWAY THE Cil I'S ABILITY TO EMF.RGl ANY
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMAT' N
APPLICATION APPROVAL
GIVEN IS CORRECT AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
T11. .1pl-11— il - - PII—I U"I" �'g�"` �Y
THEOWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
0
CALL
Ouddl.9 Offi—I .1 himAN., O-P-IY: nd F P-ld 1
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE LEMPLOI E
IN VIGIL TI.N 1p7E R CODE OF THE STATE OF WASHINGTON RE ATING TO
FOR INSPECTION ,,,,pi i, .--lodg-1 1p— p—d.d.
WORKMENS C# N�TA'o I.NSURANCE AND RCW iS.27.
OFFICIALS SIGNATURE DATE
DATE S17'ED
LI
(425)
p
SIGN�ATUA�OENT)
/ /
0
I
771 -022
RELEASED By DATV
ATTENTION
EXTJ333
IT IS UNLAWFULTO USE 1111 OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINALOPILER YELLOW - INSPECTO
ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - 'NE GOLD -
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