20030705.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINISS
NAIVE 14ARRI . S / EiWW AS hWESfenb &ffi
MAILING ADDRESS
1/5' S'lh AM
CITY ZIP TELEPHONE
40maes
NAME
ADDRESS
CITY ZIP I TELEPHONE
NAME ICBLN
ADDRESS
CITY ZIP I TELEPHONE
STATE LICENSE NUMBER EXPIRATION DATE I CHECKED BY
PROPERTY TAX ACCOUNT PARCEL NO.
O'NEW
1:1 RESIDENTIAL
PLUMBING/MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
1:1 MULTIFAMILY
AIGN
REPAIR
[3 GRADING
CYDS
[3 FENCE X
FT)
DEMOLISH
13 TANK
OTHER
IGARAGE
CARPORT
-1 RETAININGWALL
0 ROCKERY
FIRE SPRINKLER
FIRE ALARM
OWE OF USE, BUSINESS OR ACTINT
.M EXPLAIN
REPOWE `I�KD -54AI Wid AJ 46 VV
;UMBER
NUMBER OF
CRITICAL
OF
DWELLING
I
AREAS
I
STORIES
UNITS kza
DESCRIBE WORK TO
BE DONE f
-NUMBER
RIE-ft WF_ it WITW
Mew nwe
HEAT SOURCE GLAZING % LOT SLOPE %
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PLjkN CHE94tffl: _,, _ I VESTED DATE
THIS PERMIT AUTHOREMS ONLV THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERUITAPPUCATION: IeODAYS
PERMIT LIMIT: I YEAR - PROVIDED WORK 15 STARTED WITHIN 190 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 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 VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 10.27.
SIGNATURE.(OjN3Ryh GE6
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PERMIT EXPIRES
1
USE PERMIT
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ADDRESS
SUITE/APT#
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
7ESCP Approved
AW Pormit Required
Street Use Permit Req'd
EXISTING - PROPOSED
inspection Requited
Sidewalk Required
REQUIRED DEDICATION— FT
Underground
Wiring required 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
I
YES 1:1 NO 13 35
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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REVIEWED BY
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FIRE REVIEWED BY DATE
VARIANCE OR CU
SHORELINE OR ADBN
INSPECTION
BOND
RE"D
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SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALL�W�ED PROPOSED
ALLOWED PROPOSED
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EXP
LOT COVERAGE
REQUIRED SETBACKS (Fr.)
tROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT URSIDE REAR
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PARKING
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:UVI GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [j YE LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 1108/FINAL INSPECTION REO'D
$
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Description
FEE
Description
FEE
Plan Check
:T_i� —
State Surcharge
Building Permit
City Surcharge
Z6
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapeinsp.
Total Amt. Due
Recording Fee
Receipt #
APPLICATION
APPROVAL
CALL
This application Is not a permit until signed by the
Building Official or histher Deputy: and Fees are paid. and
R INSPECTION
receipt Is acknowledged In space provided.
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL - ;Ili - YELJLOW - IN4S*PEOR
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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