20030725.pdfDATE RECEIVED
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PER�MIT
CITY OF EDMONDS
USE PERMIT
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NUMBER
CONSTRUCTION PERMIT APPLICATION
JOB SUITE/APT#
ADDRESS
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PLAT NkME/SUBDIVISION NO. LOT NO. LID NO.
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ADDRESS
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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NAME BL#
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VALUATION
Description FEE Description FEE
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Plan Check State Surcharge
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PLAN CHECK NO: VESTED DATE
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THIS PERMIT AUTHORIZIES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION OR THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMITAPPLICATION: 1130 DAYS
ILI PERMIT LIMM I YEAR - PROVIDED WORK is STARTED wrrHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT; ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review Plan Chk. Deposit
IN INTEREST, AGREES 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 NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscapelnsp. Total Amt. Due
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DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINAN E
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NOR LIMIT IN ANY WAY THE C"S 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;- 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 This application Is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
Building Official or his/her Deputy: and Foes are paid, and
IN VIOLATI R CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION receipt Is acknowledged In space provided.
WORKMEN' INSURANCE AND RCYY 18.27.
OFFICIALS DATE'
JIG,IINURE
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CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
MAILING ADDRESS
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TIESCP Approved
RW Pem* Required
Street Use Pannh R@q'd
CITY ZIP TELEPHONE
Inspection Required
EXISTING — PROPOSED Sidewalk Required
LDM OAJO!5 EO 0
REQUIRED DEDICATION— IFT Underground
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NAME
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 13 NO 13
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ADDRESS
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
CITY ZIP TELEPHONE
NAME BLN
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ENGINEERING REVIEWED BY DATE
ADDRESS
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NUMBER UMBER OF CRITICAL
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STORIES- UNITS NUMBER 14Lf��
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REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REaD 9
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VALUATION
Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
T
Building Permit City Surcharge
PLAN CHECK NO: VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHOPIMMS CULY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I= � BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
Grading
:3 DOMAIN (CURB$, SIDEWALKS. DRWEWAVS, MARWEES, ETC.) WILL REQUIRE
SEPARATE PER111029ION.
t:
Engr. Review
PERMITAPPLICATION: 180 DAYS
UMM I YEAR - PROVIDED WORK 15 STARTED WITHIN 180 DAYS
rzngr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON 801ALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORB
Fire Review Plan Chit. Deposit
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, APJSING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT, SHALL, NOT BE
Ljindkape Insp. Total Amt. Due
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF AN=YFTY ?ADI4ANCE
ANY E
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE qRDI . %WISION,'
-a
Recording Fee
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
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 This application Is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
LA
IN VIOLAT Bon CODE OF THE STATE OF WASHINGTON RELATING TO
I
Building Official of hieftier Deputy: and Fees are paid, and
FOR INSPECTION receipt I* acknoviriedged In space provided.
WORKME rJON INSURANCE AND RCW 18.27.
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OFF1wL8 tj!URE�A
SIGNATUR OWNER 04 AGES DATE
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL -FILE - YELL
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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PINK -OWNER * Gii�
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