20030447A.pdfM
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEfNAM1,1F 111r/
.6 -
, -A
NAME
ADDRESS
CITY
)HESS
TELEPHONE
�6 , ZIP T;Yd
ZIP
NAME ICBL#
CITY ZIP TELEPHONE
STATE LICENSE NUMBER EXPIRATION DATE I CHECKED BY
NO.
NEW
RESIDENTIAL
PLUMBING/MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MUL11FAMILY
SIGN
REPAIR
GRADING CYDS
vCp( FE
X e6 FT)
DEMOLISH
[j TANK
j
OTHER
[3 GARAGE
RETAINING WALL
0
FIRE SPRINKLER
CARPORT
ROCAERY
FIREALARM
(rYPE OF USE
MINESS OR,ACyVrM EXP�VN:
NUMBER
OF
NUMBER OF
DWELLING
CRITICAL KlrtzF7
AREAS
STORIES
UNITS
NUMB 6W on�;
DESCRIBE WORK TO BE DONE
HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHECK NO: VESTED DATE
THIS PERurz AwrHOREM-8 OW THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
2 DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
3 SEPARATE PERMISSION.
PERMITAPPLICATION: 180DAYS
PERMIT LIMM I YEAR - PROVIDED WORK 18 STARTED WITHI" 160 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON SE14ALF or 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
EEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
OR LIMIT IN ANY WAY THE CITVS ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN 18 CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH C17Y 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'SFgr%SATION INSURANCE AND RCVV 18.27.
SIGNATIlk(OWNE R�41E ED
ATTENTION
r"
ilik
WIRES
PERMIT F
USE PERMIT
ZONE e��
NUMBER
JOB #
ADDRESS
PLAT NAME/SUBDIVISION NO.
LCVO,
LID NO.
LID FEES
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Rowifed
Stroot Use Permh Req'd
EXISTING - PROPOSED
fraWtion Required
Sidmalk RequIrW
REQUIRED DEDICATION- FT
I Undawound
I Wong fect 13
METER SIZE
LINE SIZE
NO. OF FIX'URESj
PRV REQUIRED
I
YES E3 NO 13 z
REMARKS
I
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
BY DATE
FIRE REVIEWED BY DATE W
Cr
10
VARIANCE OR CU
SHORELINE OR ADS#
INSPECTION
BOND
REQ'D
I
POSTED
I
13YEs ONO
$
SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
-.Xp ,
,
,
LOT COVERAGE
REQUIRED SET13ACKS (FTj
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LIRSIDE REAR
LOT AREA
PLANNING REVIEWED BY DATE
PARKING
REO'D I PROVIDED I
I
REMARKS
CHECKED BY
IWY F CONSTRUCTION
C012E.
0GEWPANI
1
0*11-ar
77
GROI�'
SPECIAL INSPECT
OCCUPANTf
REQUIRED, [] YE
LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 10WFINAL INSPECTION REaD
VALVMI lulm
Description FEE Description FEE
Plan Check State Surcharge
Building Permit City Surcharge
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscape Insp.
Total Amt. Due
Recording Fee
Receipt # ILI/
d
CALL
FOR INSPECTION
(425)
771-0220
EXT 1333 C,
APPLICATION APPROVAL
APP'
This application Is not a permit until signed by the
T h pp'i'c
B I 'a�
c
Building Official or hisfher Deputy: and Fees are paid, and
uild ng
receipt Is acknowledged In space provided.
..Ipt
CIAL NATURE DATE
ZZ 0 h 1h
REL SED-BY /ATE
-------------
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
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