20020724.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
IER NAMEINAME OF BUSINESS
MAILING ADDRESS
CITY ZIP TELEPHONE
17
NAME
57. .5,41.
ZIP ITELEPHO
I I NAME
Iewe ADORES
0
-7,,07
II CITY zip
41 JIVY-.0 SOV U!
UEE-NSE NUMBER
TAX ACCOUNT
E
ANEW RESIDENTIAL
ADDITION
COMMERCIAL
[3 CC
REMODEL
MULTIFAMILY
ML
0 REPAIR
JVGRADING CYDS
0 DEMOLISH
0 TANK
pC/RETAINING WALL
IGARAGE
I CARPORT
6401,ROCKERY
I(TYPE OF US . BUSINES
*OR ACTIvrM EXPLAIN:
NUMBER e7
r
N ER OF
OF
DWELLING
Z2
STORIES
UNITS
DESCRIBE 0—IRK TO BE
DONE
CBL #
BY
PLUMBING/MECH
COMPLIANCE OR
13 CHANGE OF USE
13 SIGN
FENCE
( _X FT)
OTHER
FIRE SPRINKLER
FIRE ALARM
CRITICAL
AREAS a A
NUMBER /W
PERMIT EXPIRES
,V
I
USE PERMIT
ZONE NUMEIEFtRog
SUITE/APT#
JOB
ADDRESS
LOT NO,
PLAT NAMEISUBDIVISION NO. LOT NO.
LID NO.
LID FEE $
7ESCP APPCOVOd
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Requ:,fed 'd
St,sat Use Perm Req'd
Inspection Requited
EXISTING — PROPOSED
Sidewalk Requil6d
REQUIRED DEDICATION— FT
undeforound
widna teouLred 13
NO. OF FIXTURES
METER SIZE LINE SIZE 71
PRV REQUIRED
13
YES NO 13 Z
z
9
REMARKS
RESPONSIBLE FOR EROSION CONTROUDRAINAGE
OWNER/CONTRACTOR
I
FIRE REVIEWED BY
BY DATE
DATE
U
VARIANCE OR CU
SHORELINE QH AutJff
EC T 10 N
INSP—ECTION
N S P
OND
BOND
8
EQ D
REO'D
R
I J$
STED
POSTED
P 0
11
N
13YEs 13NO
3 Y S 0 $
SEPA REVI
SIGN AREA HEIGHT SED
ALLOWED PROPOSED ALLOWED PROP
COMPLETE
XEMPT
E EMPT
EXP
LOT COVERAGE
REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR FRONT
UR SIDE REAR
z
PARKING
ANN'NG RE
LOT AREA I PLANNI VIEWED BY
DATE
HF: GLAZING % LOT SLOPE %
PLAN CHECK NO: IfL_ VESTED DATE
THIS PERMIT AUTHORUES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
E DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
0 MARQUEES, ETC.) WILL REQUIRE
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS,
SEPARATE PERMISSION.
PERMIT APPLICATION: 160DAYS
PERMrr LIMM I YEAR - PROVIDED WORK is STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMrr FOR MORE INFORMATION
'APPLICANT; ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY 0
EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
I HERE13Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATIO = RANCE AND RCW 18,27.
I — . I I DATE SIGNED
__ LA
REaD I PROVIDED
CHECKED By :U
SPECIAL INSPECTIO
REQUIRED [] YES
REMARKS
PER UBC
OCCUPANT
LOAD
2
INSPECTION REO'D 1 13
1_9
n
Description
DO " '0
S C Pt
esc'ipt'o
FEE Description I FEE
FEE D n
I ec k
Ch
Plan Check
a n
State Surcharge
State Surcharge
Pe m it
Building Permit
ui di
I ng r
City Surcharge
City Surcharge
Plumbing
f
M c ir I
Lqechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapeinsp.
Total Amt. Due
Recording Fee
Receipt #
APPLICATION APPROVAL
This appucaucin is not a permit until signed by the
CALL
Building offlcial or his/her Deputy: and Fees are paid, and
FOR INSPECTION receipt Is acknowledged in space provided.
OFFIC S SIGNAT DATE
(425)
f
771-0220
E SED Y -4DATF/
EXT 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
E AND APPROVAL OR A CERTIFI- ORIGINAL - FILE YELLOW - INSPECTOR
A FINAL INSPECTION HAS BEEN MAD SECTION 109 PINK -OWNER GOLD -ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC U ARE MAKING 5 COPIES GREEN - ACCOUNTING
04102 PRESS HARD -YO