20030561.pdfI
DATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
ADDRESS
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CITY ZIP TELEPHONE
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NAME CBL#
ADDRESS I
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER E X P MIR A3'01dO �'E' 41 — ICH16C WKE—D
ACCOUNT
NEW
RESIDENTIAL
PLUMBING/MECH
ADDITION
COMMERCIAL
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COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING CyDS
FENCE X
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DEMOLISH
TANK
OTHER
GARAGE
CARPORT
RETAININGINALL
ROCKERY
0 FIRE SPRINKLER
FIRE ALARM
(ME OF USE, BUSINESS OR ACTWM EXPLAIN: 5C
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NUMBER
OF
NUM13ER OF
DWELLING 17
CRITICAL
AREAS
1 V114
STORIES
UNITS
NUMBER
DESCRIBE WORK TO BE DONE
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HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHEC_K 40: VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIIT COVERS WORK TO
BE DOME ON PRIVATE PROPERTY ONLY. AIRY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 160DAYS
PERMIT LIMM I 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
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
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY 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
WORKMEWS COMPENSATION INSURANCE AND RCW 18.27.
DATE §(GNP
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NUMBER
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JOB
ADDRESS
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SUITE/APT#
PLAT NAME/SUBDIVISION NO.
LOT NO,
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Required
Street Use Peffnit Req'd
EXISTING -
PROPOSED
tropectlon Required
Sidewalk Required
REQUIRED DEDICATION- FT
Und"Wound
WiringrequLred
METER SIZE
UNE SIZE
NO. OF FIXTURES
PRV REQUIRED
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YES[3 NO 13
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
EVIEWED BY DhITE
FIRE REVIEWED BY DATE
VARIANCE OR CU
SHORELINE OR AD1111
INSPECTION
BOND
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REO'D
I EffyEs 13NO
POSTED
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$EPA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED ROPOSED
HEIGHT
ALLOWED ED
PROPOS
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14' 0) '_
LOT COVERAGE
REOUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (FT)
ALLOWED PROPOSED
Nc�
FRONT SIDE REAR
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FRONT URSIDE REAR
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PARKING
REO'D I PROVIDED 1
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LOT AREA
PLANNING REVIEWED BY DATE
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CHECKED BY JTYPEO�FTRUCT CODE OCCUPANT
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SPECIAL INSPECT'ION JAREA OCCUPANT
REQUIRED [] YE LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC IOD/FINAL INSPECTION REG'D 12i
$
1
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
Plumbing
Mechanical
Grading
Engr. Review
))A
Engr. Inspection
Fire Review
Plan Chk. Deposit
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Fire Inspection
Receipt #
Landscapelnsp.
Total Amt. Due
Recording Fee
Receipt #
ka
CALL
FOR INSPECTION
(425)
771-0220
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Foos are paid, and
receipt Is acknowtodgod In space provided.
Or11,LS SIGNATU DATE
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Rij-94 8 E D'B V
ATTENTION G/ Off 1 33
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL L V_/M A A & 4 1
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL -FILE - YELLOw-INSPEc-P6R
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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