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DATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
ZIR NAMEINAME (Y-BUSINESS . � / I Al
MAILING
NAME
ADDRESS
CITY
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STATE LICENSE NUMBER
PROPERTY
0
ADDITION
0
REMODEL
0
REPAIR
0
DEMOLISH
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GARAGE
CARPORT
9
TELEPHONE
ZIP TELEPHONE
ZIP I TELEPHONE
PARCEL NO.
0 RESIDENTIAL
><COMMERCIAL
0 APARTMENT
0 GRADING CYDS
0 TANK
0 RETAINING WALL
POCKERY
iS OR ACTIVITY)"PLAIN:
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COMPLIANCE 08
CHANGE OF USE
SIGN
FENCE
0 ( _X FTI
ER
RENEWAL
NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
STORIES UNITS NUMBER
DESCRIBE WORK TO BE DONE
HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHECOO��
VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
W
06 PERMIT LIMIT* 1 YEAR - PROVIDED WORK IS STARTED WITHIN 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
3 EDMONDS, WASHINGTON. ITS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLYOR 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
01 NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
I HEREBY 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 COMPENSATION INSURANCE AND RCW 18.27.
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PERMIT 'O;t -&FW
NUMBERA 4k��
SUITE/APT#
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LOT NO. LID NO.
LID FEE $
TIESCP Apprmod 0
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required
0
Street Use Permit Req'd
[3
EXISTING — PROPOSED
Inspection Required
0
Sidewalk Required
0
REQUIRED DEDICATION— FT
Underground
Witing required
M ---
ETER SIZE
I LINE SIZE
NO. OF FIXTURES
I
PRV REQUIRED
YES 13 NO 0
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
ENGINEERING REVIEWED/DATE
FIRE REVIEWED BY DATE W
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VARIANCE OR CU
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INSPECTION
BOND
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POSTED
;t��WREO'D
Y
YES 0 NO
SEPA REVIEW
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SIGNAREA
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'ALLOWED
COMPLETE EXEMPT
ALLOWED PROPOSED
PROPOSED
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EXP
LOT COVCFIAG'E
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT UPISIDE REAR
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PARKING
LOT AREA
PLANNING REVIEWED BY DATE00 I
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REO'D I PROVIDED
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IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
5198
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CHECKEDBY ITYPE.MC-6 STRUCTION CQPE OCCUPANT
'V: I GROUP
SPECIAL INSPECTOR JAREA OCCUPANT
REQUIRED 0 YES LOAD
REMARKS
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PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REOID a
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VALUATION
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
ENG. REVIEW FEES
ENG. INSPECTION FEE
LANDSCAPING
PLAN CHECK DEPOSIT
TOTAL AMOUNT DUE RECEIPT
FEE
APPLICATION APPROVAL
This application is not a permit until signed by the
CALL Building Official or his/her Deputy: and Fees are paid. and
FOR INSPECTION receipt is acknowledged in space provided.
(425) OFMFIGNAT DATE
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771-0220 D /bATE
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771-0221
ORIGINAL - FILE - YELLOW - INSPE40R
FAX PINK - OWNER - GOLD - ASSESSOR
FINAL PROJECT APPROVAL FORM
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