20030006.pdfL3
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMENME OF BUSINESS , 7 7
.J- 15
MAILING ADDRESS
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CITY
NAME
ADDRESS
CITY
NAME
CITY
STATE LICENSE NUMBER
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ZIP ITELE
ZIP ITELEPHONE
, I CBL #
ZIP TELEPHONE
NEW
RESIDENTIAL
ADDITION
COMMERCIAL
13 REMODEL
0-0—GEFAMILY
EPPAIR
0 GRADING CYDS
[:] DEMOLISH
0 TANK
[3 GARAGE
CARPORT
RETAJNINGWALL
ROCKERY
(TYPE OF USE. BUSINESS OR ACTIVITYI EXPLAIN:
NUMBER
OF
NUMBER OF
DWELLING
STORIES
UNITS .9—
DESCRIBE WORK TO BE DONE
7—
PERMIT EXPIRES
S E
SE PERMIT
Z 0 N E
ZONE NUMBER
JOB
J 0 B
A D D R E S S
ADDRESS ovo P4
11SUITE/APT#
/
L 60
PLAT NAME/SUBDIVISION NO.
P L A T N A
LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
P U B LI C I
7ESCP P4 P'Z�rl
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AW P.,-'K'R d
Street Use P58ffntl ROcfd
P
EXISTIN(
EXISTING PROPOSED
Inspection RoquIred
sidewalk Roquired
REQUIRED DEDICATION— Fr
Unclerground
Wir$ng requked cl
METER 'SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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YES13 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE J_
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r-UAS[17E1q1 10 UPC ho-57 I
SHAf,L BE INSTALLED ON THE
REVIEWED BY DATE
FIRE REVIEWED BY DATE 1 11 .1"r
VARIANCE OR CU SHORELINE& ADB# INSPECTION BOND
'ION DATE I CHECKED By REO'D POSTED
10YEs 13NO S
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE , EXEMPT ALLOWED , PROPOSED ALLOWED I PROPOSED
EXP
LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (Fr.)
N MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT L/RSIDE REAR
U G
EOR z
9�CLHANBI'E 0C USE
PARKING LOT AREA FPLANNING REVIEWED By DATE CL
SIGN REOD PROVIDED
FENCE I I
( X FT) REMARKS
OTHER
;RE SPRINKLER
FIRE ALARM
CRITICAL
AREAS
NUMBER
HEAT SOURCE T_7U�N_G % LOT SLOPE %
PLAN CHECK NO: I VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON T14E PUBLJC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT: I YEAR - PROVIDED WORK IS STARTED WTTHIN 180 DAYS
SEE BACK OF PINK PERMIT 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 OF
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 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
GIVEN IS CORRECM 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.F�ENSA�TION INSURANCE AND RCW 18.27.
SIGNATUR� �(OWN.ER R AGEI�M DATE SIGNED
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CHECKED BY TYPE OF CONIBTRUCTION CODE � OCCUPANT
GROUP
SPECIAL INSPECT16N kREA OCCUPANT
REQUIRED [] YES LOAD
REMARKS
PROGRESS INSPECTIONS PER LIBC 11081FINAL INSPECTION REG'
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
I
Fire Inspection
Receipt #
Landscape Insp.
Total Amt. Due
Recording Fee
Receipt #
LLV_—
CALL
FOR INSPECTION
(4-25)
771-0220
APPLICATION APPROVAL
n is not a permit until signed by the
a I .Or his/her Deputy: and Fees are paid, and
AWO ptisacknowladjpdlnsptceprovlded,
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1 / gW 1,7 701.
/ /tWSED BY I DATE
ATTENTION "1133
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL -FILE YELLCW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
FINAL PROJECT APPROVAL FORM
TO:
DATE:
PERMIT COORDINATOR, BUILDING DIVISION
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
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