20040110.pdfDATE RECEIVED
USE
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CONSTRUCTION PERMIT APPLICATION
PWNER NAME/NAME OF BUSINESS
M��G ADDRESS
CITY ZIP TELEPHONE
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PROPERTY TAX ACCOUNT PARCEL NO.
TELEPHONE
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TELEPHONE
EXPIRATIgN DATE I CHECKED
NEW
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ADDITION
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REMODEL
MULTIFAMILY
REPAIR
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TANK
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CARPORT
ROCKERY
(*P6 OF USE. BUSINESS
qR ACTIV EXPLAIN:
NUMBER
NUMBER OF
OF
DWELLING
STORIES
UNITS
DESCRIBE WORK TO BE DONE
EAT SOURCE GLAZIjj %
PLAN CHECK NO: Z\
PLUMBING / MECH
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FIRE SPRINKLER
FIRE ALARM
NUMBER
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LOT
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ADDRESS
PERMIT EXPIRES `7
PERMIT
NUMBER
SUITE/APT#
PLAT NAME/SUBDIVISION NO.
LOT NO�
LID NO.
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LID FEE S
'EsCP App" d
PUBLIC RIGHT
OF WAY PER OFFICIAL
STREET MAP
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Street Use Pidred Heq'd
EXISTING
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inspriction acquired
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REQUIRED DEDICATION
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LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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YESPIK NO 13
REMARKS
OWNERICONTRAClOR RESPONSIBLE FOR EROSION CONTROODRAINAGE
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FIRE REVIEWED BY DATE W
VARIANCE OR CU
SHORELINE OR ADB#
INSPECTION
I BOND
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POSTED
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IS
SEPA REVIEW
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SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
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REQUIRED SETBACKS (FT)
PROPOSED SETBACKS (FT)
ALLOWED PROPOSED
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PLANNO/413 REVIEWED BY DATE
11!�D I PROVIDED
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FT) I REMARKS
TYPE OF
SPECI�I_ INSPECTION AREA
(71 —_ - -
I REQUIRED [] YES
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURDS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180DAYS
PERMIT LIMIT., I YEAR - PROVIDED WORK IS STARTED WITHIN 100 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 NA1 URE, ARISING DIRECTLY OR INDIREC RLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF I HIS PERMI1 SHALL NOT BE
DEEMED 70 MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITY'S ABILITY 10 ENFORCE ANY ORDINANCE PROVISION.'
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
GIVEN IS CORRECT; AND THAT I AM TIIE OWNER, OR THE DULY AUTIORIZED AGENI OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WORK AUTIIORIZED TIIEREBY, NO PERSON WILL 13E EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COM PEN SATIOK.IN SU RANCE AND RCW 18 27,
SIGNATU N__R�E N DATE SIG
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OCCUPANT
GROUP
OCCUPANT
LOAD
REMARKS a
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D A
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VALUATION
$ M, V�-
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
LandscapeInsp.
Recording Fee
11A nA.
FEE
Description
State Surcharge
City Surcharge
Base Fee
.210
CALL
FOR INSPECTION
(425)
771-0220
ATTENTION r E)ff 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING Oil STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FEE
Plan Chk. Deposit .,)()c
Receipt it
Total Amt. Due
Receipt #
APPLICATION APPROVAL
I his application is not a paiinit until 3igned by the
Building Official or his/her DLpuly: and Fees are Paid, and
receipt is acknowledged in space provided,
OFFICIALS SIGNATURr
ATE
TITEIV-AS" HY 'I
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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