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[PERMIT EXPIRES
CITY OF EDMONDS
USE PERMIT
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NUMBER
CONSTRUCTION PERMIT APPLICATION
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ADODRESS
OWNER NAME!
15 V5 I < C 415�, 4 F_ F;?--
PLAT NAMEISUBDIVISION NO. LOT NO.
LID NO.
MAILING ADDRESS
LID FEE $
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TF.5GP Approved
RW Peffnh Required
CITY ZIP TELEPHONE
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EXISTING PROPOSED---
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REQUIRED DEDIC ON FT
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METER SIZE LINE SIZE NO. OF FITTURES PRV REQUIRED
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY
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REMARKS
PROGRESS INSPECTIONS PER UBC I 06/FINAL INSPECTION REG-0
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HEAT SOURCE JLTNG % LOT SLOPE %
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PLAI0HECK NO: 05— VESTED DATE
THIS PERMIT AUTHORIZES ONLY 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.
PEAMrTAPPLJCATION: 160DAYS
PERMIT UMM 1 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, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, IT$ 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 HE
I DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CrrY`S 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 PLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
To C(3MP
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 18.27.
SIGNATUT/,OW�NER I DATE SIGNED
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Descriptlon
FEE
Description
FEE
Plan Check
Building Permit
State Surch arge
City Surcharge
Plumbing
Mechanical
Ha
Grading
Engr. Review
Engr. Inspection
Fire Review
PlanChk Deposit
Fire Inspection
Receipt #
Landscapeinsp.
Total Amt. Due
Recording Fee
Receipt #
CALL
FOR INSPECTION
IA-05)
771-0220
APPLICATION APPROVAL
This application is not a permit Until signed by the
Building Official of his/her Deputy: and Fees are paid, and
receipt Is acknowledged In space provided.
OFFICIALS SIGNATURE
RELEASE9 BY DATE
ATTENTION EXT I JJ
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL — , - _101:;1L-
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINJ(L-FA YELLOW- INSPEaroR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINIQ�OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
GARY HAAKENSON
MAYOR
ton on your
ore are no
permit. file.
The City considers the final inspection to be one of the most importani inspections
be complete:
approval the following: nust
conducted on a project In order to grant final
ara
numbers, guardrails, handrails, -close door, between g ge
self
smoke detectors, house
rooms, safety stopp
glazing, weather- ing, any
and residence, egress from sleeping
ese may
gs
etc. Of course not all of these
g department requirements
Engineerin hZIdni
about th kinds of things
apply to your project but it does give you an idea
s cc
specifically
lete as well as some items that do not need to be ins ed such as:
that must be comp etc. Please be advised permits expire one year from
paint, carpet, moldings, wallpaper,
he work, permits can be
the date of issuance. If you will need more time to complete t a final
renewed prior to expiration for one half fees. If the permit expires
in '.der to renew the
approval granted by the Building Inspector, full fees are required
ourage to c your
permit. This can be very costly to you and we strongly enc yol
(s). Note: if more than
permit expiration date and call for the required fina inspection
one department is required to final your project, this is noted on your Job Card.
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USE PERMIT
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CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB u,,,,
ADDRESS qZ14 W At)tr( t)-r
OWNER NAM
PLAT NAME/SUBDrvisION NO.
LOT NO.
LID NO.
LID FEE
MAILING ADDRESS
92-4- HAP L F_
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
7ESCP APPMVId
RW Pofn-A RequWed
EXISTING PROPOSED
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S" Use Perm" 11160
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UnderlywW 99
CITY ZIP
TELEPHONE
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REQUIRED DEDICATION
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NAME
METER SIZE
LINE SIZE
NO. OF F06`UAE,9FT
PRV REQUIRED
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ADDRESS
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REMARKS
OWNER/CONTRACTOR REIPO JBLE
FOR EROSION CONTROLIDRAINAGE
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CITY ZIP-
r:::DMOKYD5�
TELEPHONE
-714-IIZI
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ENGINEERJNG REVIEWED BY
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ADDRESS
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PDRESS/
-ffRE REVIEWED BY
DATE
CITY -zip TELEPHONE
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STATE LICENSE NUMBER EXPIRATION GMEWWD BY
OL I
M I $
PROPERTY TAX ACCOUNT PARCEL NO.
SEPA REVIEW SIGN AREA H HT
COMPLETE EXEMPT ALLOWED., - PROPOSED ALLOWE 6SED
EXP
0 NEW RESIDENTIAL PLIUMBING MECH
LOT COVERAGE REQUIRb SET13ACKS (FT.) P OSEED tri.)
ALLOWED PROPOSED FRONT SIDE REAR qT 5"521EAR
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COMPLIANCE OR
ADDITION COMMERCIAL CHANGE OF USE
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PARKING LOT AREA, PLANNING R EWED 1
PROVIDED . lov,
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FENCE
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CYDS FMT)
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CARPORT ROCKFRY FIRE ALARM
I[TYPE OF USE. BUSINESS OR ACTIVITY) EXPLAIN:
CHECKEDBY .4ONSTRUCTION OCCUPANT
ITYPEDF r\j GROUP
NUMBER NUMBER OF R A
C 'no L,
OF DWELLING AREA S
2-
SPECIAL INSPECTION OCCUPANT
LOAD
STORIES UNITS NUMBER
JAREA'
REQUIRED . . .
DESCRIBE WORK TO BE DONE
DID CA R_ F6 P, T V F_ C k- 170 r.
REMARKS
PROGRESS INSPECTIONS PER UBC 10IMNAL INSPECTION RECtEl.
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ly 0 LIV I M 611
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. . . . . . . . . . . . . .
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Description FEE Description FEE
Plan Check
State Surcharge
th
HEAT 80 G % LOT SLOYE %
Building Permit City Surcharge
P05UHECK NO: VESTED DATE
Plumbing 1_Q00,
Mechanical
00
THIS PERMIT AUTHORMES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DOME ON PRIVATE PROPERTY ONLX ANY CONSTRUCnON ON THE PUBLIC
Grading
DOMAIN (CURBS. SIDEWALKS, DRIVIEVANS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
W. Review
PERMIT APPUCATION. 1150DAYS
PER= umm i YEAR - PROVIDED WORK IS STMMD WITHIN 100 DAYS
Engr. Inspection
SEE BACK OF PINK PERMff FOR LWRZLIN!P��'Tlok
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEI . R49, ASSIGNS AND SUCCE I SORS
Fire Review Plan.Chk. Deposit 51
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, ANSING DIRECTV( OR INDIRECTLY
_eF3 _-tP
FRO UANCE OF TH IS PERMrr. ISSUANCE OF THIS PERMIT SHALL NOT BE
M THE ISS
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
ndscapelnsp.
La Total Am. Due
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Be Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; A* 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 Feet are paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION receipt 13 acknaMedgod In space pcqM*d.
WONXMENS COMPENSA71ON INSURANCE AND RCW 10.27.
OFFICIALS SIGNATURE DATE
SIGNATUF E JOV�NER PR fgb' DATE SIGNED
IA05)
�ul �1 03
Ila �m
771-0220
RELEASEI?i0Y OAT E
ATTENTION
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. ORIGI01 F - YELLOW-INSPE OR
4
W,:,' CATE OF OCCUPANCY HAS BEEN GRANT ED. UBC SECTION 109
PINK-04ER - GOLD -ASSESSOR
GREEN - ACCOUNTING
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES