20030719.pdfI
DATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNE MEINAME OF BUSINESS
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CITY TELEPHONE
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NAME
ADDRESS
CITY ZIP ITELEPHONE
NAME CBLN
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ADDRESS
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TELEPHONE
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STATE LICENSE NUMBER E
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PROPERTY TAX ACCOUNT PARCEL NO.
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UMBING MECH
NEW ESIDENTIAL _xPCL0tMPLthNCE OR
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13 ADDITION 0 COMMERCIAL CHANGE OF USE
[3 REMODEL 0 muLnFAmiLy SIGN
GRADING Ei FENCE
1:1 REPAIR 11 CYDS ( X FT)
DEMOLISH 1:3 TANK 0 OTHER
EGARAGE -1 RETAININGWALL FIRE SPRINKLER
l CARPORT 0 ROCKERY FIRE ALARM
UWE OF USE, BUSINESS OR Aaw"Sfv
NUMBER NUMBER OF CRITICAL
U
OF 7DWELLING AREAS
V
STORIES UNITS NUMBER
DESCRIBE WORK 10 BE DONE
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CE GLAZING %_ I LOT SLOPE
ECK NO: I VESTED DATE
THIS PERMIT AUTHORMES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUC7110N ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
PERMIT UMM 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, AERREES 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
FR M THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
EEMED TO MODIFY WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
OR 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 GOING TH RIZE THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LAqQR CODE THE STATE OF WASHINGTON RELATING TO
WORKMIEWS COMPENS N D49URANC AND RCW 18.27.
DATE JIGNED
U R E (=OE I RAG E N"D
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I PERMIT EXPIRES
USE PERMIT
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NUMBER
JOB W SUITE/APT#
ADDRESS lbq I ct AtIE
PLAT NAMEISUBDIVISION NO. LOT NO.
L D NO.
L�D FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP APP(OV90
RW PerffW Required
Slr@al Use Peffnit Req'd
EXISTING - PROPOSED
Inspection Required
Sidewalk Required
REQUIRED DEDICATION- FT
UndeVound
Winniaw ulred 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YESD NO 13 z
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
_6y__ - 'A DATE
FIRE REVIEWED BY DATE I I"
VARIANCE OR CU SHORELINE ORADB11 I INSPECTION BOND
REO'D POSTED
-ORC I
13YEs 13NO S
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In"DI;P; 1'.. PROPOSED I ;LLOWED . 71OPO
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LO REQUIRED Wfif .1
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AREA I PLAN By DATE
PARiING NINO REVIEWED
REO`O I PROVIDED I OT
CHECKED BY ITYPE O"rrR
GROU
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SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [] YES LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 1108/FINAL INSPECTION REG'D
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sq wfor
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
'l®r
City Surcharge
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt N
Landscape Insp.
Total Amt. Due
Recording Fee
ipt #
Leceipt #
CALL
FOR INSPECTION
1425)
771-0220
Pni IAATION APPROVAL
r-l",
T I appilc n is not a permit until signed by the
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B oildi�gOfflc or his/her Deputy: and Fees are paid, and
Offic
Nic I
ac t Is acknowiedged in space prov ad.
0 �__
0 L SIG E DATEE
112,
Y DATE
MENTION L_/ E x T I j;LRj
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFi-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
GREEN - ACCOUNTING
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNEMN, E/NAME OF BUSINESS
DDRESS'
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ECITY TELEPHONE
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NAME
ADDRESS
CITY ZIP
NAME ICBL#
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ADDRESS
TELEPHONE
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STATE LICENSE NUMBER E
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P IOPERTY TAX ACCOUNT PARCEL NO.
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03
1 1 PERMIT EXPIRES
USE
PERMIT
ZONE
NUMBER
JOB
ADDRESS
SUITE/APT#
4q -7 i(a* AJEW
PLAT NAME/SUBDIVISION NO. LOT NO.
LID NO.
LID FEE S
VUBLIC RIGHT OF WAY PER 0
TESCP Approved
RW Pannit Required
041
PROPOSED
Street Use Parmll %Wd
Inspection Required
DEDICATION— FT
Sidewalk ked
ROW
Underground
wiring required 13
METER SIZE
LINE S��
NO. OF FIXTURES
PRV REQUIRED
I
YES13 NO 13
=z
REMARKS
OWNEWCONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
BY A DATE
FIRE REVIEWED BY DATE I Mir
VARIANCE OR CU I SHORELINEORADB# I INSPECTION I BOND
SEPA MVIEW' kilt-114-ANEW ---- __._ Htlurlll
COMPLETE f r" S 91100T��Iz ED
EXP lR 48� UM qljtl-
LOT COfr-lAGE I REQUIRED sEraACKS iFrn Pnnpn.qrn sETa3AcKa Fin
1:1 NEW
A: ESIDENTIAL
PLUMBING I MECH ALLOWED -PWOPD
TW
ADDMON
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
PARKING
SIGN RECYD I PROVIDED
LOT AR
1 4
REPAIR
GRADING CyDS
FENCE X 01111111 r1l
FT) REMARKS
DEMOLISH
TANK
0
OTHER AU
GARAGE
CARPORT
RETAININGWALL
ROCKERY
F RE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACT1VTrY)tjyW
_-) r R I .
NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
STORIES UNITS NUMBER
DESCRIBE WORK To BE DONE
gel-f -F---u rn
q61CS00 VAU'C' Locc*-)
BY -TYPE 01,ttSIR�MWIbN
CHECKED I [V
SPECIAL INSPECTION JAREA
REQUIRED [] YES
REMARKS
I PROGRESS INSPECTIONS PER UBC 1
GROUP KZ:y
OCCUPANT
LOAD
INSPECTION REG'D
P1
L4 L't r
VALUAnON
VX.� 4!4 C� IC 16ca-troc)
U0A.r 6 ('ec 00 C_ I Description
FEE
Description
FEE
Q3A CA's 4- - -z - 5
Plan Check
State Surcharge
HEAT 80 CE GI LOT SLOPE %
9
Building Permit
City Surcharge
PLAICCHECK NO: VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORGMS ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
3 DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS. MARQUEES, ETC.; WlLL EQUIRE
Z F1
SEPARATE PERMISSION.
Engr. Review
PERMIT APPILICATIOW 180DAYS
PERMIT UMM I YEAR - PROVIDED WORK 18 STARTED WITHIN 100 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF OF HIS OR HER S�ousr:, HEIRS, ASSIGNS AND SUCCESORS .
Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE C17Y OF
EDMONDS, WASHINGTON, ITS OFFICLUZoEMPLOYEES, AND AGENTS FROM ANY AND
Fire'Inspection
Receipt #
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, WAIVIE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscapeinsp.
Total Amt. Due
NOR LIMIT IN ANY WAY THE CTTTS ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee
ecelpt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
LI
A PP ON APPROVAL
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-
CALL
T41 appil n Is not a permit Until signed by the
(
TION. AND IN DOING THS IZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LAQQR CODE THE STATE OF WASHINGTON RELATING TO
G
B 1IdI Offic or hlsfhar Deputy, and Fees are paid, and
11,
FOR INSPECTION I Is acknowledged In space pyv)ded.
WORKMENS COMPENSYEONIKMSURANC AND RCW 18.27.
OF I BIG E DATE
SIGURTURE (OWEA qR #GEN1j DATE
')1
IA95)
ZIGNIED
It 9q't I (
771-0220
DATE
ATTENTION C-7
EXT 1333
_��LeEXBY
IT IS UNLAWFUL TO USEOR 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
04102 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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