20030906.pdf4
DATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS I
CITY IF ZIP I TELEPHONE
NAME
ADDRESS
CITY ZIP I TELEPHONE
NAME
PERMIT EXPIRES
USE PERMIT
ZONE NUMBE",M-,4
JOB
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sLrrrE/APT#
ADDRESS
PLAT NAME/SLIBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW PerrrJ1 Required
Street We Parmit RKd
EXISTING - PROPOSED
Inspection Required
Sidewalk Required
REQUIRED DEDICATION- FT
1 Underground
uired 13
METER SIZE
LINE
-1410-.-OF-FIXTURE�_i
PRV REQUIRED
Vks U-No,
REM S
0 E5(CONTR!�TOR RESPONSIBLE FOR EROSION CONTROQDRA�INA'..,'
REVIEWED BY
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FIRE REVIEWED BY
DATE
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ENSE NUMBER CH
VARIANCE OR CU
SHORELINE OR ADS# INSPECTION i BOND
REQ'D POSTED
113YEs
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ONO $
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SEPA REVIEW
SIGN AREA HEIGHT
PROPETITY TAX ACCOUNT PARCEL NO.
COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
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EXP ,
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NEW RESIDENTIAL PLUMBING / MECH
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LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/RSIDE REAR
COMPLIANCE OR
ADDITION COMMERCIAL CHANGE OF USE
-_ I I I
REMODEL MUI.TFAMILY [3 SIGN
PARKING
AEQ'D PROVIDED
LOT AREA REVIEWED BY DATE
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TO 13CDC 19-30.020
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PR
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DEMOLISH TANK [:] OTHER
ME I-NiSTA ; i ED bM AR
-
WAUR SHWOFF
GARAGE RETAINING WALL F RE SPRI NKLER
CARPORT ROCKERY FIRE ALARM
(ME OF USE, BU I SS OR ACTIVITY) EXPLAIN:
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CHECKED TYPq
BY
OF C ?IISTRUCTION OCCUPANT
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GROUP
NULIWR NUIIABER OF CRITICAL
2 DWELLING AREAS
2&4'Le
SPECIAL INSPECTION
- JAREA OCCUPANT
LOAD
UNITS NUMBER
REQUIRED
nr-nFRjBi= WnRk T( ONE
REMARKS
PROGRESS INSPECTIONS PER UBC I 08/FINAL INSPECTION REGV
A NAM SMKE SHUTOFF
VALUATION
BE INSTALLED ON THE
$
Beffi-DING
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit
City Surcharge
PLAN CHECK NO: VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRTVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBILIC
Grading
2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
3 SEPARATE PERMISSION.
t:
Engr. Review
PERMITAPPILICATION: 180DAYS
06 PERMIT ILIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
)--A
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 INDEMNIF'� DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
ALL CLAIMS FOR DAMAGES Or WHATEVER MATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMTT. ISSUANCE OF THIS PERMIT SHALL NOT BE
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Total Amt. Due
DEEMED TO MODIFY WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CI1YS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Recording Fee
Receipt # &Z?12
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 Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION receipt Is acknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
ALS SI!,14AIURE E
SIGNATURE (OWNER 01 DATE SIGNED
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&RELEAS
771-0220 DATE7
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IT IS U 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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