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DATE RECEIVED
CITY OF EDMONDS 2
CONSTRUCTION PERMIT APPLICATION
OWNER E/NAMIE OF BUSIN-:SS
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CITY ZIP
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STATE LICENSE NUMBER EXPIRATION DATE
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PRIOPEW -ACCOUNT PARCEL No.
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4 0
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ADDITION COMMERCIAL COMPLIANCE OR
CHANGE OF USE
REMODEL MULTIFAMILY 0 SIGN
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REPAIR Mr CYDS 13
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0 DEMOLISH 1:1 TANK o OTHER
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OWE OF USE, BUSIN EXPLAIN:
NUMBER NUMBER OF
CRITICAL
OF DWELLING
STORIES ZL, UNITS It
AREAS
NUMBER
DESCRIBE WORK TO BE DONE
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HEAT SOURCE
GLAZING %
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PLAN CHECK NO:
VESTED'DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
It:
BE DONE ON PRIVATE PROPERTY ONLM ANY CONSTRUCTION ON THE PUBUC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMFTAPPIUCATION: 1180DAYS
CL
PERMIT IUMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERUIT 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 CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
I HERE13Y 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 AMORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLA5=.N.O�F I E OF WASHINGTON RELATING TO
ENSATIO SURANCE AND RC 18.27.
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LOT NO.
LID NO.
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LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP AP
RW Permit=ed
Street Use Permit Req'd
EXISTING - PROPOSED
'Inspection Required
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! Sidewalk Required
REQUIRED DEDICATION- FT
Underwound
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METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES E3 NO 13
IEMARKS
)WNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
AN.
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31PECIAL INSPECTION JAREA UtAXPArAl
aEQUIRED [:] YES LOAD
EMARKS
IROGRESS INSPECTIONS PER UBC I GOMINAL INSPECTION REO'D
VALUATION
Description
FEE
Description
FEE
Plan Check
Ma
State Surcharge
Building Permit
City Surcharge
Plumbing
Mechanical
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Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Ch k. Deposit
Fire Inspection
Receipt #
Landscapelnsp.
-TotalAmt.Due
Recording Fee
I Receipt #
CALL
FOR INSPECTION
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1425
771-0220
APPLICATION APPROVAL
This application Is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receipt Is acknowledged In space provided.
OFFICIALS SIGNATURE DATE
11-AY)
Y DATE
ATTENTION M 1333 A J. I.,lf Arxz
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL &2&- __..0 I
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL - FILE - YELLOW fINSPEC AR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER - GOLD -ASSESSOR
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