20030033.pdfDATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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CITY ZIP TELEPHONE
NAME
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ADDRESS
CITY
ZIP
TELEPHONE
NAME
CBLN
ADDRESS
11 CITY ZIP I TELEPHONE
[PERMIT
EXPIRES
USE PERMIT
ZONE M_
Z&3
NUMBER
JOB
SUITEIAPT#
ADDRESSI 5e LA
PLAT NAMEISUBDIVISION N
LOT NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
Rw Pefrnft Roqu:red
Street Use Perm t Req'd
EXISTING — PROPOSED
Inspection Required
Sidewalk Required
REQUIRED DEDICATION— FT
Underground
Wiring required CI
METER SIZE
LINE SIZjTO.
OF FIXTURES
PRV REQUIRED
YES 13 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CQNTROLIDRAINAGE
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011
FIRE REVIEWED BY DATE us
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IE
VARIANCE OR CU
SHORELINE OR ADS#
INSPE 'ON
BOND
STATE LICENSE NUMBER EXPIRATION DATE
CHECKED BY
I
I
RE07D
POSTED
I
13YES ONO
1$
SEPA REVIEW
SIGN AREA
HEIGHT
PROPERTY TAX ACCOUNT PARCEL NO.
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED
PROPOSED
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,
,
,
-9
se .2.=
EXP
0 NEW
PLUMBING / MECH
LOT COVERAGE
REQUIRED SETBACKS (FT.)
SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT URSIDE REAR
d9WL ADDITION
"In
�CRESIDENTIAL
COMMERCIAL
COMPLIANCE OR
El CHANGE OF USE
ALLOWED PROPOSED
FRONT
z
r7:;_0P
PARKING
LOT AREA
PLANNING REVIEWED DATE
4'ff-EMODEL
MULTIFAMILY
SIGN
REO'D
I PROVIDED
REPAIR GRADING CYDS
FENCE
( X FT)
REMARKS
XDEMOLISH 1:3 TANK
[3 OTHER
oGARAGE [3 RETAINING WALL
F RE SPRINKLER
0
CARPORT ROCKERY
FIRE ALARM
(TYPE OF USE, BUSINESS OR LAIN:
ffic
IV I
CHECKED BY
41ONSTEr
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T
"I'
I %4
OCCUPANT 0 '7
GROUP It .001
NUMBER
OF
NUMBER OF
DWELLING
CRITICAL
AREAS
_12r
'�ko
SPECIAL INSPECTION
OCCUPANT
LOAD
STORIES
UNITS
NUMBE;i�
JAREA
REQUIRED 0 YES
DESCRIBE WORK TO BE DONE
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A
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REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REG'D
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to
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VALUATION
01,— L
$
En v io
Description
FEE
Description
FEE
0
?N P.T
Plan Check
State Surcharge
HE*r SOURCE G I A SLOPE
Building Permit Z=
City Surcharge
f2
PLAN CHECK NO: VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORUIS ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBILIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMITAPPILICATION: 180DAYS
PERMIT ILIUM I YEAR - PROVIDED WORK IS STARTED WITHIN 160 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT 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
M EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
Fire Inspection
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
Landscapelnsp.
Total Amt. Due
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."
Recording Fee
I HERE A KNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION APPROVAL
IVEN IS CORRECT. AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
a c tion Is not a permit until signed by the
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
CALL B Idin
I 1��'
cla or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
acelpt acknowledged In space provI 2 d.
WORKMEN-S.WNW INSURANCE AND RCW 18.27.
0
S S NATU;RE _.A2 DATE
_kNMTION
SIGNATUR(RWNER AGfdlf�) I DATE SIGPED
IA03r-%
/1
771-0220 I DATEI
R E L A
F 10) SIN
ATTENTION
EXr 1333
---------------
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 - YELLOW -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