20040289.pdfDATE fiECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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STATE LICENSE NUMBER EXPIRATI N DATE
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PROPERTY TAX ACCOUNT PARCEL NO.
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SIGN
REPAIR
FENCE
GRADING CYDS ( — X — FT)
0 DEMOLISH
TANK
OTHER
GARAGE
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FIRE SPRINKLER
FIRE ALARM
CARPORT
ROCKERY
[TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
A
NUMBER
OF
NUMBER 01
DWELLING
CRITICAL I V
AREAS C)
STORIES
UNITS
NUMBER
DESCRIBE WORK TO BE DONE
FIRE REVIEWED
RESPONS113LE FOR E
VARIANCE OR CVOR
SEPA REVIEW
COMPLETE EXEMPT
EXP I
LOT COVERAGE
ALLOWED PROPOSED
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HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHECK NO: 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 APPLICATION: 180 DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE 13ACK OF PINK PERMIT FOR MORE INFORMATION
,APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
IN INTERESf, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS. WASHINGTON, ITS OFFICIALS. EMPtOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIREC rLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF I HIS PERMIT SHALL NOT HE
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. -
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
IV
GIVEN IS CORRECT; AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
T T I ' STATE LAWS REGULATING CONSTRUC-
HE OWNER. I AGREE TO COMPLY WITH CITY AND
I
T T lo�
ION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
V
IN VIOLATION OF THE LABOR CODE OF TIIE STATE OF WASHINGTON RELATING TO
Woi
WORKMEN'S C SATION INSURANCE AND RCW 111,27.
I
S lot -6R AGENT) DATE SIG ED
SIGN�� (,i7� 4
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PARKING
REO'D I PROVIDED
REMARKS
CHECKED BY
SPECIAL INSPECTIO
REQUIRED [3 YES
WITH
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DATE
DEMOLITION INSPECTION
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BOND
POSTED
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SIGN AREA riciull,
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REQUIRED SETBA (Fr.) PROPOSED SETBACKS (FT.)
FRONT SIDE R R I FRONT UR SIDE REAR
LOT AREA I PLANNING REVIEWED BY DATE
OCCUPANT,
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01.
REMARKS
PROGRESS INSPECTIONS PER UBC `108/FINAL INSPECTION REG'D
5M
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
CALL
FOR INSPECTION
(4:25)
771-0220
[=V-r -11 010101
Plan Chk. Deposit
Receipt #
Total Amt. Due L4�
Receipt # i�2 7
APPLICATION APPROVAI
i his application is not a permit until signed by the
Building Official or his/her Deputy: and Fees art, paid, and
receipt is acknavviedged in space provided,
M-CIO SIGNATURE// j4T E
AfTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
ED BY f DA
ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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