830497.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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tuMAILING ADDRESS 1
TELEPHONE NUMBER
13u//,
TELEPHONE NUMBER
NUMBER
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CITYLICENSE NUMBER
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• Include all easements
PERMIT
NUMBER
[PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
TING_-_._._... REQUIREDDEDICATIONPOSED__-__ _. HT OF WAY CONSTRUCTION PERMIT REQUIRED I I
EET USEPERMIT REQUIREDENGINEERING MEMO DATED
PIW DEPT. REVIEW CHECK LIST DATED ..-..- ._.-----
NEW
❑ RESIDENTIAL
1-1PLUMBING
ty..l ADD/ALTER
❑ NON-RESIDENTIAL
❑ MECHANICAL
/❑, REPAIR
❑ RETAINING WALL
❑ SIGN
❑ DEMOLISH
❑ OR FILL
❑ FENCE x_ FT)
PRE, MID : IN%l
COMPLIANCE INSP.
SWIM
POOL
❑ SIDE SEWER ❑ WATER LINE
❑
❑
❑
❑
NUMBER OF STORIES
NUMBEROF
DWELLING
NATURE OF WORK TO BE DONE (ATTACH
UNITS
PLOT PLAN)
n
ALLOWED I PROPOSED I COMPLETE I EMIT SHOflELINEM
VARIANCE OR CU
FRONT fU SIDE Ze BEARI`p✓/(J /y'v
REMARKS
CHECKED BY I TYPE OF CONSTRUCTION CODE HC113
- I� Iq Zq ►51
SPECIAL INSPECTOR AREA OCCUPANCY OCCUr
REQUIRED GROUP N A _1 LOAD
'.YES NO �Y�
REMARKS
I?Q.oGR, 5 1I,SOacrlaoS PEG2p
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
This Permit covers work to be done on private property ONLY.
GRADINGIFILL
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission.
Permit Application: 180 Days
Permit Limit: 1 Year- Provided Work Is Started Within 180 Days
"Applicant, on behalf of his or her spouse, heirs, assigns and
successors in Interest, agrees to indemnify, defend and hold
1 harmless the City of Edmonds, Washington, its officials,
employees, and agents from any and all claims for damages of
whatever nature, arising directly or indirectly from the issuance
of this permit. Issuance of this permit shall not be deemed to
I modify, waive or reduce any requirement of any city ordinance
nor limit in any way the City's ability to enforce any ordinance
TOTAL AMOUNT DUE
provision."
I hereby acknowledge that I have read this application; that the
information given is correct; and that I am the owner, or the duly
ATTENTION
authorized agent of the owner. 1 agree to comply with city and
THIS PERMIT
slate laws regulating construction; and in doing the work authoriz-
AUTHORIZES
ed thereby, no person will be employed In violation of the Labor
ONLY THE
Code of the State of Washington relating to Workmen's Compensa-
wORK NOTED
tion Insurance.
INSPECTION
S TUHE (OWNER OR AG ENTI DAT SIGNE ) .�
DEPARTMENT
CITY OF
EDMONDS
0
APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or his
Deputy; and fees are paid, and receipt is
acknowledged In space provided.
OFFICIAL'S SIGNATURE
THIS SITE IS LOCATED IN THE CITY I'
OF EDMONDS. LOCAL SALES TAX 775-2525 DATE
ATTENTION SHOULD BE CODED 31.04.
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR ORIGINAL — File YELLOW — Inspector
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED, UBC SEP
CHAPTER 3. PINK — Owner GOLD — Assessor
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