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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMENAME OF BUSINESS
ZIP JTEIIP"ONE
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NAME
CITY ZIP ]TELEPHONE
NAME
ADDRESS
= I PERMIT EXPIRES
USE PERMIT 1&i
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FLAT NAME/SUBDIVISION NO, I LOT No, LID NO,
LID FEE S
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REQUIRED DEDICATION— FT — U=_
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OWNERCONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
REVIEWED By
DATE
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REMARKS
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PROGRESS INSPECTIONS PER UBC 10811FINAL INSPECTION REQ'I
VALUATION
FEE
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THIS PERMIT AUTHO IZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
R I K 0
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-
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON TH "C
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R K
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ENG. REVIEW FEES
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0.
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0 R M NF
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U C B.'
.-.S. H.' -S ASSIGNS AN. E C E.-RS
-A PLICANT. ON BEHAL OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
S E.T'.N FEE
ENG. INSPECTION FEE
NO IN P
'Y
A E. E IT OF
1. INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
IN.
LANDSCAPING
AN.SCAP
,u N
I EDMONDS.WA HINGTON. ITS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANYA"D
S EC,
E
INSPECTION FEE
C LY 0
ALL CLAIMS FOR DAMAGESOFWHATEVER NATURE. ARISING DIRECTLYOR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
NY FE-U, EVENT FANY CITY ORDINANCE
DEEMED TO MODIFY, WAIVE OR REDU E ANY REQUIREMENT OF ANY CITY ORDINANCE .
C
ORDINANCE PR VISION.
TO OR N OF NG P V'S
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY DINA E .0 N
T DUE
TOTAL AMOUNT DUE
FIPTq(o 15
I HEREBY ACKNOWLEDGE THAT� HAVE READ THIS APPLICATION. THAT THE INFORMATION
A ICATION APPROVAL
GIVEN IS CORRECT. AND THAT AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
T�O
I TE LAW REDULA" . CON B tFUC
THE NER I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONStRUC
OW
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LL
CALL
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TION.ANDIN ONG HEWORK AUTHORIZED THEREBY. No PERSON WILL BE LEMPLOIED
D I E Y . P FS. W, L
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W SHI L To
OF A NGTON RE ATING 0
WASHI
0 1 S P C TIC
FOR INSPECTION
S, I ,
A
LAI ON OF THE LABOR CODE OF THE STATE
IN VIO I
WORKMEN S.COMPENSATION INSURANCE AN2/RCW IE27,
OF.Cl IGNATURE E
SIG ENT)
(425)
771-0220
P11. A D6y
krTXTION
EXT 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDiNG OR STRUCTURE UNTIL 771-0221
HAS BEEN MADE AND APPROVAL OR A CERTIFI-
A FINAL INSPECTION
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
-OWNER -ASSESSOR
PINK GOLD
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEJNAME OF BUSINE S
CIE eq w 1*110,19
MAILING ADaRess
TELEPHONE
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ffl�
XPIRES,
USE, PERMIT ,
ZON NUMBER Lim - ob 0(f
SUITEJAPT.
ADDRESS //,c Al
PLAT NAMEISUBDIVISION NO. I LOT No,
LID 0,
LID E"
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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EXISTING- PROPOSED�
R
REQUIRED DEDICATION- FT
U.._
0-
PRV REQUIRED
YES 0 NO 0
I
REM
tRKSnNTAArTOR RESPONSIBLE FOR EROSION CONTROtlDRAINAGE
EN.INEER.. FEVIEWEDIDATE
ADDRESS
CITY ZIP TELEPHONE FIRE REVIEWED By DATE
VARIANCE OR C U
SHORELINE OR ADS.
INSPE.CTION
NO.
COTE
STATE LICENSE NUMBER
EXPIRATION GAT E
4wItA Apr
tE D
IPB
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C31EE Mtq
SERA REVIEW
COMPLETEEXEMPT
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ALLGW!:!.� PROPOSED
tLOT
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ALLOWED PROPOSED
PWT(j I�UTCJCECfa, & 00
DI
Co
EXP
EXP
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REQUIRE SETBACKS (FT)
PROPOS D SETBACKS (FT.)
0 NEW
0 RESIPENTI L
'M.'NG'MECH
0 LUMBINGIMECH
ALLOWEDC PROPOSED
FRONT SIDE RE R
FRONT UP SIDE FEAR
0 ADDITION
COM
0 MERC;AL
-p"A.CE OR
COMPLIA CE OR
CHANGE OF USE
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I
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AREA
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.RnrArqR INSPECTIONS PE R UBC 10811FINAL INSPECTION REOT 2
VALUATION I FEE
CIA CK FEE
PLAN CIA
LA
HEAT SOURCE GLAZING I
LOT SLOPE %
'
BUILD"'(
N
BIN
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LU ""IN
PLAN CHECK NO:
JVISIEDGATI
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.E�-AN'CAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
L BE DONE ON PRIVATE PROPERTY ONLK ANY CONSTRUCTION ON TKE PUBLIC
U
DOMAIN (CURBS. SIDEWALKS. DRIVEWAY MARQUEES. ETC.) WILL BEG IRE
SEPARATE PERMISSION.
L'
GRADINGIFILL
'N.'F'L'
KREE
S F. R
STATE SURCHARGE
-T T U
PERMIT APPLICATION; IBODAYS
PERMIT UMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 130 DAYS
SEE BACK 0 INFORMATION
, ,
VW E
E S
ENG. REVIEW FEES
EN
-APPLICANT ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
IN NTEREST, AGREES TO MDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
I EDMONDS. WASHINGTON. ITS OFFICIALS. EMPLOYEES, AND AGENTS FRO. ANY AND
c SING DIRECTLYOR IND RECTLY
ALLCLAIMS FOR DAMAGESOFWKATEVER NATURE.ARI
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SMALL NOT BE
9 DEEMEOTO MODIFY.WAIVE OR REDUCE ANY REQUIREMENTOF ANY CITY ORDINANCE
0 NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
ENG. INSPECTION FEE
END SPECT-.N FEE
LANDSCAPING
N APING
LA Sr
IN SFE.".H FEE
INSPECTION FEE
PLANCHECKDEPOSIT
TOTAL AMOUNT DUE
RECEIPT
R El
REC
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORREC THE DULY AUTHORIZED AGENT 01
I AD T, AND THAT I A. THE OWNER. OR
THE OWNER FEE To COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
D
TION. AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYE '
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TOIJFORf�-,INSPECTION
WORKMEN S_929,PENSATION INSURANCE AN AC. 18.27.
TN
CALL
S
OFMCS
7
SIQN=R AGEN� I DATq SIG NED
(425)
1
ATTOTION
'771-0220
EXT 1333
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-
CATE OF OCCUPANCY HAS BEEN GRANTED. LED SECTION 109 FAX
see
p. d..
id.d.
ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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