20030336.pdfDATE RECEIVED G—
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CITY OF E�DMONDS ZONE
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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PERMIT
NUMBER
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP APPMv0d
Rw PsirWt Required
street use Peffnit Req'd
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TELEPHONE
EXISTING — PROPOSED
inspection Required
Sidewalk Required
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REQUIRED DEDICATION— FT
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NAME
METER SIZE LINE SIZE NO. OF FIXTURES
PRV REQUIRED
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ADDRESS
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
CITY
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NAME
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ENGINEERING REVIEWED BY
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STATE LICENSE NUMBER
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EXPIRAT N DATE
VARIANCE OR CU
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LOT AREA PLANNING REVIEWED BY DATE
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REPAIR
GRADING o FENCE
CYDS ( X FT)
REMARKS
0 DEMOLISH ATANK
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IGARAGE
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FIRE ALARM
(rYPE OF USE. BUSINESS OR
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NUMBER
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NUMBER OF
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SPECIAL INSPECTION
JAREA OCCUPANT
LOAD
STORIESt+
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NUMBER
REQUIRED [] YES
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 109/FINAL INSPECTION REG'O
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VALUATION
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Description
FEE Descriptlon FEE
Plan Check
State Surcharge
HEAT SOURCE
GLAZNG %
LOT SLOPE %
VESTED DATE
Building Permit
Plumbing
Mechanical
City Surcharge
PLAN CHECK NO:
THIS PERMrr AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBUC
A
Grading
DONUUM (CURBS, SIDEWALKS, DRIYEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMITAPPILICATION: 180 DAYS
IL PERMIT 1.1111117111 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICAN17; ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFX DEFEND AND HOLD HARMLESS THE CITY OF
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
9 DEEMED TO MODIFY: WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscape Insp.
Total Amt. Due
NOR LIMIT IN ANY WAY THE CnY8 ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Recording Fee
Receipt 0
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1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION
APPROVAL
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 CONSTRLIC-
CALL
This applicaUon Is not a permit unfit 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 Is acknovAedgod In space provided.
WORKMEN'S COMPE AT19N_AISI.WNCE AND RCW 18.27.
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OFFICIALS SI ATUR IRATY
SIGI TURE (OWNER /(GENII
DATE SIGNED
1425)
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771-0220
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IT IS UNLAWFUL TO USE OR 0 UPYABUIL�l��NCG�UORV14StTRtU4CkRVEUN4TIdL�,?i�)D,3
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
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CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
ORGINAL-FILE YELLOW- INSPECTOR
P�NK-OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE
MAKING 5 COPIES
GREEN - ACCOUNTING
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