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CITY OF EDMONDS
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US9 PERMIT
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CONSTRUCTION PERMIT APPLICATION
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OWNER NAMPNAME OF BUSI EBB
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PLAT NAMEISUBDIVISION NO. LID NO.
LOT NO.
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LID FEE $
MAILING ADDRESS
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TESCP App"wed
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Requitod
Street Use Parmit Roq
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CITY ZIP TELEPHONE
EXISTING — PROPOSED Inspection Required
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METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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REMARKS
OWNER]CONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
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NAME CBLN
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CARPORT ROCKERY FIRE ALARM
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Description FEE Description FEE
Nr Plan Check State Surcharge
HEAT SOURCE
GLAZING %
LOT SLOPE %
Building Permit
City Surcharge
PLAN CHECK NO:
VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DOME ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
3 SEPARATE PERMISSION.
Engr. Review
PERMI'll'APPLICATION: 160 DAYS
L PERMIT UMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION -
N BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
;APPU
N INT=TOAGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
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 REOUIREMENIT OF ANY CITY ORDINANCE
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Total Amt. Due
NOR LIMIT IN ANY WAY THE CrTYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Recording Fee
Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION
APPROVAL
GIVEN IS CORRECT, %D THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
This application Is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
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
FOR INSPECTION
receipt Is acknowledged In space provided.
WORKMEN,S,5pMr6I�S ION INSURANCE AND RCW 18,27.
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OFFICIALS RE --7 DATE
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SIG N41Tf("(WiNER O�AGENT)
DATE S!PNED
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771-0220
RELEASED BY
ATTENTION
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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-
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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DATE RECEIVED
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CITY OF DIVIONDS ZONE NUMBER az
JOB SUITIVAPT#
CONSTRUCTION PERMIT APPLICATION ADDRE::LZ/,,2,
OWNER NAMUME OF BUSINESS
^1 APL- I PLAT NAMEISUBDMSION NO. LOT NO. LID NO.
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MAILING ADDRESS
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NAME
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STATE LICENSE NUMBER EXP RATI �N D TE CH.�,
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PROPEF17Y ACCO PARCEL NO.
0-10
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0 NEW
0 RESIDENTIAL
0 PLUM.BING/MECH
0 ADDITION
0 COMMERCIAL
COMPLIANCE OR
0 CHANGE OF USE
REMODEL
muLnFAmILY
0 SIGN
0 REPAIR
0 GRADINq CYDS
FENCE X
( FT)
DEMOLISH
TANK
OTHER
GARAGE
RETAININISWALL
FIRE SPRINKLER
CARPORT
4tc. KERY
FIRE ALARM
(TYPE OF USE, BUSINE OF! EXPLAIN:
NUMBER
OF
NUMBER OF'
DWELLING
CRITICAL
AREAS A
STORIES
UNITS
NUMBER
DESCRIBE WORK TO BE DONE
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HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHECK NO," VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DOVE ON PRIVATE PROPERTY ONL% ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERUTTAPPILICATION: 180 DAYS
PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
I!EE BACK Or PINK PERMIT F.1DR_MORE INrORMATION. -
'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 CIAiMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMITASSUANCE 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 ABIL17Y TO ENFORCE ANY ORDINANCE PROVISION."
I HERESY 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 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
WORKMEr?:,R=ON INSURANCE AND RCW 18.27.
m� I DATE SIGNED I
ninmAumf 7bimpn nAAnr n Y
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCF Apprond
RW Penns Required
Street Use Parmit PAO
EXISTING - PROPOSED
Inspection PAquIred!
Sidewailt Required
REQUIRED DEDICATION- FT
Underground
WMg required 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
I
I 13
YES 13 NO 13 z
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLfDRAINAGE
ENGINEERING REVIEWED BY A�a e,-, I DATE
FIRE REVIEWED BY DATE Lu
cc
IEL
-VARIANCE OR CU SHORELINE OR ADIIII I INSPECTION BOND
REQ'D POSTED
DYES ONO $
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE . EXEMPT ALLOWED . PROPOSED I ALLOWED , PROPOSED
LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIRSIDE REAR
FIRE MARS - imp CPO
PARKING WNW% IBNrv"DATE
GiT
RE0`D I PRO IDED i 12MHOW oR CAP
CHECKED BY ITYP N N I CY7 OCCUPANT
GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [3YES LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION RE
$
Description FEE Description FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
Plumbing
%
Mechanical
Grading
Engr. Reiview
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapoinsp.
Total Amt. Due
Recording Fee
Receipt #
CALL
FOR INSPECTION
025)
771-02:20
APPLICATION APPROVAL
This application Is not a permit unto signed by the
Building Otficial or hIs1her Deputy: and roes are paid, and
receipt Is acknowledged In space provided.
OFFICIAIrSNA�IURE E
RELEASED 13Y DATE'
ATTENTION "U 1 33
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 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-ACCOLINTING
I