20030440.pdfRECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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NAME
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PLAT NAME/SUBDIVISION NO.
NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
Rw Parroft Required
Street Use Parrnft Req'd
EXISTING - PROPOSED
Inspeetkin Required
Sidewalk Required
REQUIRED DEDICATION- FT
Underground
wiring requited cl
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
1
1
YES13 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
REVIEWED BY DATE
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DATE ut
FIRE REVIEWED BY
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STA7 LICENSE NUMBER EXPIRATION DATP
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SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOW51D PROPOSE i
ALLOWE� PROPOSED
PROPERITY TAX ACCbb'NT PARCEL. NO.
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NEW RESIDENTIAL PLUMBING/MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIAED SETBACKS �`T)
FRONT SIDE REAR
PROPOSED SETBACKS (FT)
FRONT URSIDE REAR
COMPLIANCE OR
ADDITION COMMERCIAL CHANGE OF USE
PARKING LOT
PROVIDED
AREA
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PLANNING REVIEWED BY D IL
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CARPORT ROCKERY FIRE ALARM
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OCCUPANT
GROUP
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OF USE, BUSINESS OR ACT N:
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NUMBER NUMBER OF OVW I CRITICAL
OF DWELLING AREAS
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SPECIAL INSPECTION
OCCUPANT
LOAD
STORIES UNITS NUMBER
JAREA
REQUIRED [] YE
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS
PER UBC 108/FINAL INSPECTION REG'D
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VALUATION
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Description
FEE
Description
FEE
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Plan Check
2-C. 3tate Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
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Building Permit
City Surcharge
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PLAN CHECK NO: VESTED DATE
Plumbing
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Mechanical
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLX ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMITAPPUCATION: 180DAYS
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PERMIT ILIMM I YLAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit / 4k_.1,
IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
a EMPLOYEES, AND AGENTS FROM ANY AND
EDMONDS, WASHINGTON, ITS OFFICIALS,
Fire Inspection
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
-
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
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Total Amt. Due
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CRYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.
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Recording Fee
Receipt
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
E OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
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CALL
This application Is not a permit until signed by the
Building Otficial or his/her Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
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IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR
receipt Is acknowledged In space provided.
WORKMENS COMPENS:��NCE AND RCW 18.27.
ATURE DATE
SIGNATU E (0 ER ORt(GENT) DATE SIGNED
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IT IS UfWFU TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A FINAL IINBP7:TION 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
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