20051139.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAM&NAME OF BUSINESS
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LICENSE NUMBER EXPIRATION DATE C KED BY
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PROPERTY TAX ACCOUNT PARCEL NO.
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PLUMBING/ MECH
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COMPLIANCE OR
CHANGE OF USE
REMODEL
APARTMENT
SIGN
REPAIR
GRADING
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FENCE
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DEMOLISH
TANK
OTHER
GARAGE
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NUMBER
NUMBER &
CRITICAL
OF
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AREAS
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UNITS
NUMBER
DESCRIBE WORK TO BE DONE
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PERMIT EX PIRES
USE PERMIT
ZONE NUMBER
JOB e� SUITE/APT#
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PLAT NAME/SUBDIVISION NO. LOT NO, LID NO.
LID FEE S
TESCP Apipmved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP AW Permit ReqUired
street Use Permit Req d
EXISTING - PROPOSED inspection Required
Sidewalk Recitlifed
REOUI RED DEDICATION - FT Underground
wiring tecluired
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
In addition to the required
pressure/relief vaWe, an approved
listed expansion tank shall be
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FIRE REVIEWED BY DATE- Lu
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BOND
ors required
on
COMPLSTF� ROPOSED ALL OWED , PROPOSED
EXP
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LJR SIDE REAR
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PARKING PLANNING REVIEWED BY
VIDEO] LOT AREA DATE
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OCCUPANT
GROUP I
SPECIAL INSPECTOR
REQUIRED (:] YES
JAREA OCCUPANT
:1LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D
VALUATION
FEE
PLAN CHECK FEE
HE4T SOURCt
GLAZING %
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LOT SLOPE
BUILDING
PLUMBING
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PLAN CHECK NO:
VESTED DATE
MEe"AN4eAL
C)
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADING/FILL
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
STATE SURCHARGE
LU PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT: I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FORMORE INFORMATION
U)
U) "APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
LANDSC
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2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
.APITZ'
JN9,wffTION FEE
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sw /cWtV
cc ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
RECE T
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x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
a DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANYCITY ORDINANCE
_j
NOR LIMIT IN ANY WAY THE CITY'S ABILITYTO ENFORCE ANY ORDINANCE PROVISION."
RECEg
TOTAL AMOUNT DUE
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 hisnier Deputy: and Foos ate paid. and
IN VIOLATION OF THE ��C R CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt is acknowledged in space provided.
WORKMEN'S COMP5p&"0MqSU.FANCE AND RCW 18.27.
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OFFI�l ATU
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SIGN URE I R OR A J)
DATE SIGNID
.(425)
771-0220
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RELEAS
DATt
YV
ATTENTION
EXT 1333
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
L
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - OWNER GOLD - ASSESSOR
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