20050662.pdfDATE RECEIV��
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PERMIT EXPIRES
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NUMBER
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ADDRESS
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PLAT NAME/SUBDIVISION NO.
LOT NO.
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LID FEE S
PUBLIC RIGfiT OF WAY PER OFFICIAL STREET MAP
TIESCP Approved E3
AW Permit Required [3
Street Use Permit Hoq'd E3
EXISTING - PROPOSED
Inspection Required 13
Sidewalk Required 13
REQUIRED DEDICATION- FT
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iring required E3
METER SIZE
LINE SIZE _FNO
OF FIXTURES
PRV REQUIRED
YES13 NO 13
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY
DATE
FIRE REVIEWED BY DATE UJI
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STATE LICENSE NUMBER EXPIRATION DATE CWCKED By
VARIANCE OR CU
SHORELINE OR ADBI
INSPECTION
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POSTED
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SEPA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED OSED
PROP
PROPERTY TAX ACCOONT PARCEL
,
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NEW RESIDENTIAL PLUMBING MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (Fr.)
FRONT L/R SIDE REAR
ADDITION COMMERCIAL COMPLIANCE OR
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CHANGE OF USE
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REMODEL MULTIFAMILY
PARKING
ID
LOT AREA
PLANNING REVIEWED BY DATE
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SIGN
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REPAIR GRADING FENCE
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REMARKS
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DEMOLISH 2' TANK El
MUE3T BE PhESENT FOR
[D GARAGE E] RETAININGWALL E] FIRE SPRINKLER
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CARPORT ROCKERY FIRE ALARM
(TYPE OF USE, BUSINESS OR ACT" EXPLAIN:
CHECKED BY
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CODE
OCCUI A T
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NUMBER
REQUIRED
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DESCRIBE WORK TO BE DONE
REMARKS
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PROGRESS INSPECTIONS PER UBC 108/lBC1109/1RC109 FINAL INSPECTION REO'D
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VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit City Surcharge
PLAN CHECK NO: VESTED DATE
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
1= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
W PERMIT APPLICATION: 180 DAYS
EL PERMIT LIMIT I YEAR -PROVIDED WORK IS STARTED WITHIN 180DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) 'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt Iff
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
!3 DEEMED TO MODIFN� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
LandscapeInsp.
Total Amt. Due 5157
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Receipt #
Recording Fee
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.
OFF1 LS S GN T E DATE
S19MATU'RE (OWNER OR EN`q�'-- DATE SIqNEO
(421i)
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771-0220
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By
RELEAS D BY DATE
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=ANTIOA
EXT 1 333
ITIS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADEAND APPROVAL OR A CERTIFICATE OF OCCU-
ORIGINAL -FILE YELLOW -INSPECTOR
PANCY HAS BEEN GRANTED. UBC109/1BC110/IRC110.
PINK -OWNER GOLD -ASSESSOR
09/03
PRESS HARD -YOU ARE
MAKING 4 COPIES
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