20030621.pdfOld /111 C If, 7 ZWAI DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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CITY ZIP TELEPHONE
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NAME
ADDRESS
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UMBER EXPIRATION DATE I %IVI500
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0 NEW
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RESIDENTIAL PLUMBING / MECH
1:1 ADDITION
COMMERCIAL COMPLIANCE OR
E] CHANGE OF USE
13 REMODEL
MULTIFAMILY
0 SIGN
REPAIR
GRADING
CYDS
[3 FENCE
( — X—FT)
DEMOLISH
TANK
1:1 OTHER
GARAGE
RETAINING WALL
FIRE SPRINKLER
1:1
CARPORT
ROCKERY
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTNIM WLAIN.
NUMBER
NUMBER OF
CRITICAL
OF
DWELLING
AREAS
STORIES
UNITS
UMBER
DESCRIBE WORK TO BE DONE /9 _ / —
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I-LPERMIT EXPIRES
USE PERMIT
ZONE 'FIC, NUMBER)-46--3
ITE/APT#
ADDRESS
PLAT NAME/SUBDIVISION NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP AP
RW PartriAt"IralvVIled
Street We Permit Raq'd
EXISTING — PROPOSED
InapectionnoquIred
Sidewalk Required
REQUIRED DEDICATION- FT
UnderWound
WirintifaquM
METER SIZE
LINE SIZE
OF F XTURES
PRV REQUIRED
YEsM NO 13 3
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHEC&NQ)Lj VESTED DATE
THIS PERMrr AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DOME ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 1180DAYS
PERMIT ILIUM I YEAR - PROVIDED WORK IS STARTED WrTHIN 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 MATURE, 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 CITYS 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 VIOLAT THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN!? rco;INENSATION INSURANCE AND RCW 18.27.
SIGNATUt6WNjOR AGENT) ATE SIGNED
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
VARIANCE OR CU
HORELINE OR ADB#
INSPECTION
BOND
k
REgD _
POSTED
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44hj)JAPP.
13YES )SkO
$
SEPA REVIEW
SIGNAREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSfD
ALLOWED
I
,
,PROPOSEi
_.XP
LOT COVERAGE
REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (IR
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT URSIDE REAR
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PARKING rLOT
AREA
I PLANNING REVIEWE BY DATE
REQ`D I PROVIDED
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CHECKED BY [:�T "CTI deCOE--f OCCUPANI,:5;�<
GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [] YES LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'O
$
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—
-
Description
-_
FEE
Description
FEE
Plan Check
State Surcharge
-q-6
Building Permit
City Surcharge
Mechanical
Azview
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Ir
Landscapelnsp.
Total Amt. Due
Recording Fee
Receipt #
APPLICATION APPROVAL
CALL
This application Is not a permit until signed by the
Building Official or his/her Deputy: and Foes are paid, and
FOR INSPECTION
receipt Is acknovirledged In space provided.
OFFVLS SIGI�AT E D T
(425)
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771-0220
RELEA6121� BY
ATTENTION cf5x EXT 1333
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- OR GIN� - F -14SPEC36R
�I YELLOW
C&E OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 P�N GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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FINAL PROJECT APPROVAL FORM
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DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
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