20030761A.pdf0
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEPIAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP I TELEPHONE
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NAME
ADDRESS
CITY
ZIP I TELEPHONE
PERMIT EXPIRES
USE PERMIT
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LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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Street Use Permit Req 'd
EXISTING — PROPOSED
Inspection Required
Sidewalk Required
REQUIRED DEDICATION— FT
Underground
Wirkig required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED is
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
NAME
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STATE LICENSE NUMBER
EXPIRATION DATE BY
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ALLOWED PROPOSED FRONT SIDE REAR FRONT LIRSIDE REAR
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0 ADDITION
COMMERCIAL
COMPLIANCE OR
1-1 CHANGE OF USE
1:1 REMODEL
MULTIFAMILY
0 SIGN
PARKING
RECID I PROVIDED
LOT AREA I PLANNING REVIEWED By DATE 06
REPAIR
GRADING
CYDS
FENCE X
( FT)
REMARKS
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1:3 TANK
OTHER
[3 GARAGE
RETAINING WALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIRE ALARM
(TYPE OF USE. BU
S OR ACTIVITY) EXPLAIN:
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CHECKED BY
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NU MBER NUMBER OF
OF DWELI ING
CRITICAL
AREAS
SPECIAL INSPEcnot4
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AREA OCCUPANT
STORIES
UNITS*
NUMBER h�M
REQUIRED [:] YES
LOAD
DESCRIBE WORK TO
BE DONE
REMARKS
PROGRESS INSPECTIONS PER USC 108/FINAL INSPECTION REG'113
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voxibaix- Description FEE Description FEE
Plan Check gc)- StateSurcharge
HEAT SOURCE GLAZING % LOT SLOPE % Building Permit City Surcharge 115 ev
PLAN CHECK NO: VESTED DATE Plumbing .1D
Mechanical ar)
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBUC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
3
SEPARATE PERMISSION.
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Engr. Review
PERNITTAPPLICATION: ISODAYS
IL PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
BEE 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 CLJUMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscape Insp.
Total Amt. Due
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
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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
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
Building Official or his/her Deputy: and Fees are paid, and
receipt 15 acknowledged In space provided.
,eWORKMENS COMPENSATP4,:�4,SURANCE AND RCW 18.27.
0 SH YATjJRE DATE
SIGNATURE (OXMER OR(AGE
DATE SIGNED
(425)
MIS
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771,0220
_-VELEASECT
BY /6ATE/
ATTENTIOW_
EXT 1333
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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