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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS 1/'
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MAILING ADDRESS
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CITY ZIP ITELEPHONE So
NAME
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ADDRESS
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CITY ZIP TELEPHONE
NAME CBL 01
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ZIP TELEPHONE
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NUMBER EXPIRATION DATE
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NEW RESIDENTIAL PLUMB
ADDITION OMP
o CCHAN
REMODEL MULTIFAMILY SIGN
REPAIR
GRADING
CYDS
FENCE
DEMOLISH
TANK
OTHEF
0 GARAGE
CARPORT
RETAINING WALL
ROCKERY
FRES
FIRE
(TYPE OF USE, BUSINESS OR AMW" EXPLAIN:
fGq% IC I 11WI4
NUMBER
OF
STORIES 414,
NUMBER OF
DWELLING
1 UNITS
CRITICAL
A EAS
NUMBER
DESCRIBS WORK TO BE DONE
PERMIT EXPIRES
USE PERMIT
ZONE
NUMBER
JOB
ADDRESS U60 IV
L,61
SUITEIAPT#
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
YESCP ApPrOvId
RW Perrm Required
Street Use Permit RKd
EXISTING — PROPOSED
Inspection Required
Sidewalk Requked
REQUIRED DEDICATION—
FT
Undemround
Wkingfequired 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES E3 NO 13 z
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
VARIANCE OR CU SHORELINE OR ADBO INSPECTION BOND
KE dDBY REO'D POSTED
113YEs ONO $
SEPA REVIEW HEIGHT
COMPLETE . EXEMPT LO% )SED I ALLOWED . PROPOSED
HEAT SOURCE GLAZING % LOT SLOPE %
I - - —
PLAN CHECK NO: — — - I 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.
PERMIT APPILICATION: 160DAYS
PEI',MIT UMnl YEAR - PROVIDED WORK IS STARTED WITHIN ISO 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 WM "ZED THEREBY. NO PERSON WILL BE EMPLOYED
R
IN VIOLATION OF THE V61 Q ODE F HE STATE OF WASHINGTON RELATING TO
0
WORKMEN'S COMPENS I NIU R)A E AND RCW 18.27.
l5lRjAGENijo;7
jURE (OWNER DATE SIGNED
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0,5.r _.- ph -�rlo
CHECKED BY TYPE OF CO�STRUCTION OCCUPANT
lqr GROUPA-1
SPECIALINSPEOTION JAREA OCCUPANT
REQUIRED [: LOAD 4
PER UBC IGO/FINAL INSPECTION RECeD
q
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapelnsp.
Total Amt. Due
Recording Fee
Receipt #
CALL
FOR INSPECTION
1425)
771-0220
EXT 1333
APPLICATION APPROVAL
This application 15 not a permit Until signed by the
Builchng Official of his/her Deputy: and Foos are paid, and
receipt Is acknowledged in space provided.
KIN DATE
-RELKED BY f DATE
"AA� A j A /;l
-IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL zf/ fi=&KWZ" I
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- CRIGINAL - WSPECTIR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK - OWNER - GOLD - ASSESSOR
G4/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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M
ING / MECH
LOT COVERAGE
I REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LJR SIDE REAR
LiANCE OR
I
GE OF USE
PARKING
LOT AREA
PLANNING REVIEWED BY DATE
REO'D
I PROVIDED
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REMARKS
PRINKLER
ALARM