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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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NAME
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CITY ZIP
NUMBER
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
7ESCP Approved
RW Permd Required
street Use Peffnit Awd
EXISTING — PROPOSED
Inspection Required
Sldew&tk Required
REQUIRED DEDICATION—
FT
Undergrou.nded 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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REMARKS
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SIGN AREA
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ALLOWED PROPOSED
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FRONT
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Description
FEE
Description
FEE
Plan Check
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State Surcharge
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SOURC(.j GLAZING % LOT SLOPE %
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Building Permit
City Surcharge 5,010
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PLAN CHECK NO- VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORI(NOTED. THIS PERMIT COVERS WORK TO
tz BE DONE ON PRIVATE PROPEFITY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: ISODAYS
IL PERMIT UMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
;APIPLITEASNETiT, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
X EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER MATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapeinsp.
Total Amt. Due
DEEMED TO MODIFY, WAJVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Recording Fee
Receipt III
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPR
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-
CALL
This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
Building official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION receipt 15 acknowledged in space provided.
WORKMEN'? COMPENSATI%NjNSrNCE AND RCW 18.27.
OFFICIA S NAT AT)
DATE
"'ONArd
(425)
77/" Awj
771-0220
E
RELEASED BY
JkfT)kNTION
Off 1333
IT ISIUNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORANAL * FLE - YELLOW- RISPE&OR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK - OWN GOLD - ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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USF PERMIT V
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CITY 00 EDMONDS NUMBER go()
JOB SUITE/APT#
CONSTRUCTION PERMIT APPLICATION ADDRESS 01,
OWNER NAMEfNAM F B JSINESS
""1- 17 � At OP -A IV PLAT NAME/SUBDIVISION NO. LOT NO. L D NO.
MAILIN t RESS UD FEE S
7ESCP Approved
PUBLIC RIGHT OF WAY PER OFFICIALPEET
00 'MAI RW Perrnit Required
t, f4 0 Ai A Aj Strem Use Peffnh A -led
CITY EXISTING — PROPOSED Inspection Required
ZIP TE�FPHONE SidewsA Req fred
Wa%A jq�a 4;- -Ila /.:i Und.. u
REQUIRED DEDICATION— FT
mofds- a required 13
R �ES PRV R
NAME METER SIZE LINE SIZE NO. OF FI;T EQUIRED
[YES
13 NO 13
ADDRESS REMARKS
OWNEFUCONTRACTOR RESPONSIqLE FOR EROSION CONTROWDRAINAGE
0,%) RZI U4TS
ZIP TELEPHONE
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NAME CBL#
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ENGINEERING REVIEWED BY. DATE
111!5 tj qq Qa
— FIRE/�EVIEWED 13Y DATE
CI* ZI ELEPHONE
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VARIANCfEOR�CLI:. SHORELINE OR ADS# INSPECTION BOND
NUMBER EXPIRATIC64 DATE E REO'Q POSTED
'2 A -) C3 YE§ J&P
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j2njffj:: SEF'A�R618W SIGN AREA
PROPERTY TAX ACCOUNT PARCEL NO. COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
- 7
EXP ! _�
'LOT dOVMGE '-' -REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT)
PLUMBING MECH
0 NEW RESIDENTIAL ALLOWED �PFMPOSED FRONT SIDE REAR-' FRONT L/RSIDE REAR
CqMPLLANCE OR ..........
0 ADDIT MERCIAL
[:],COM LJ USE
.�?N CHANGE OF
PARKING -A PLANNING REVIEWED BY DATE
LOT AREAL
MUL11FAMILY
REMODEL '0 SidN REQ`D D�
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GRADING F&'CE R&LQ�i
REPAIR 'CYbs ( X,' FT) REMARKS
OTHER AAI1' IRM
11DEMOLISH TANK
T3 GARAGE RETAINING WALL Ej FIRE SPRINKLER
CARPORT FIRE ALARM Uff
ROCKERY
ffYPE OF USE, BUSINESS OR ACTIVI'M EXPLAIN:
d7A IA CHECKED TYPFJOF CONSTRUCTION CODE PtCUPAla
GROU��
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NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS SPECIAL INSPECTION JAREA OCCUPANT
9
c17 C R LOAD
UNITS NUMBE &Z& PEqUIRED rl YES
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DESCRIBIEWORK TO BE DON
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Samoa re &P.0 - 4-- Cd sa I I '�S PER WO
V -14 OGRESS INSPECTP UBC 1108/FINAL INSPECTION REC
sc"
-A. VALUATION
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^Am&U I KA A $
it 'A. -tn Descrip'tion FEE escription FEE
Plan Check
State Surcharge
HEAT SOURCEC LOT SLOPE %
GLAZING % Building Permit City Surcharge 6109
PLAN CHECK NO: VESTED DATE Plumbing
2 ��hanlcal
THIS PERMnr AUTHORIZES ONLY THE WORIfNOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
2 Grading
EWAI D 17�WAQUEEB, ETC RE
3 DOMAIN (CUR13S. SID WILL REG
L 6 !R PERM SID
ngr. Review
'666
PER mrr ARIP&A )Jb DAk
PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS 'ltn6; Inspection
SEE BACK OF PINK PRRMrT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, 11TS OFFICIALS, EMPLOYEES, AND AGENTS FROM AfftAND Fire frispection Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapeinsp. Total Amt. Due gg)
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITTS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
Recording Fee Receipt # j
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAII
GIVEN 19 CIDRRECT� 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- CALL This application Is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY NO PERSON WILL BE EMPLOYED Buliding Offic[al or hisiber Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt Is acknowledged in space provided.
WORKMEN? COMPENSATIqV_1NSyANCE AND RCW 18.27. OFFICIAL S1 NATU
9L"L 8, ATE
SIGNIAlylo (OWNER OR D EIGNE
W
V 771-0220
BY. E
[ELEASED
A NTION Off 1333
/ IlzJ-
-
IT NLAWFUL TO USE OR OCCUPY A BU'11DING OR STRUCTURE UNTIL "
ITM
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIC(I A - F YELLOW - INS'PEdTOR
N L
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK-OWNIV. GOLD -ASSESSOR
04/02 GREEN - ACCOUNTING
PRESS HARD -YOU ARE MAKING 5 COPIES
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