860142.pdfr..
CITY OF EDMONDS USE PERMIT
ZONE NUMBER
CONSTRUCTION PERMIT APPLICATION
JOSE
NAME (OR NAME OF BUSINESS) ADDRESS OO / Q,
v
al 2"Z 9 LEGAL DESCRIPTION CHECK SUBDIVISIO NO.
Cie
MAILING AD ESS r/
d�VW
CITY TELEPHONE NUMBER PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
-3 ZO � e EXISTING REQUIRED DEDICATION
NAME PROPOSED
=T11
CITY
STA
NUM
NUMBER
rty - Include all easements
copies)
Li NEW F RESIDENTIAL PLUMBING
El ADD/ALTER COMMERCIAL MECHANICAL
CIREPAIR RETAINING WALL SIGN
EXCAVATE FENCE
DEMOLISH I� OR FILL _x_FT)
❑ PRE MOVE INSPJ ❑ SWIM
REMODEL COMPLIANCE INSP. POOL
❑ WOODIN ER VE/ APT. BLDG RENEWAL
NUMBER OF STORIES NUMBER OF
DWELLING
UNITS
NATURE OF WORK TO BE DONE (ATTACH PLOT PLAN)
Cee�
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: 1 Year- Provided Work is Started Within 180 Days
MMMUMN
"Applicant, on behalf of his or her spouse, heirs, assigns and
$ successors 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 nature, arising directly or Indirectly from the Issuance
of this permit. Issuance of, this permit shall not be deemed to
modify,, waive or reduce any requirement of any city ordinance
nor limit in any way the City's ability to enforce any ordinance
provision."
1 hereby acknowledge that 1 have read this application; that the
Information 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 construction; and in doing the work authoriz-
ed thereby, no person will be employed in violation of the Labor
Code of the State of Washington relating to Workmen's Compensa-
DATE SIGNED
Q �^
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED ❑
STREET USE PERMIT REQUIRED ❑
SEE ENGINEERING MEMO DATED
METER SIZE IBUILDI
SIGN AREA
ALLOWED. I PROPOSED
VARIANCE OR CU
YARDS
FRONT
TYPE
SPECIAL INSPECTOR I AR
REQUIRED
❑ YES ❑ NO
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
GRADINGIFILL
STATE SURCHARGE
ENERGY CODE
PLAN CHECK DEPOSIT
TOTAL AMOUNT DUE
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED, UBC
CHAPTER 3,
102.78
V.
Y
ENV, REVIEW ADB NO.
COMPLETE I EX T
REAR
REVIEW BY I DATE
HEIGHT I LOT COVERAGE
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wut
l 9HEIGHT
OCCUPANCY OCCUPANT
GROUP LOAD
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ATTENTION APPLICATION APPROVAL
THIS PERMIT This application is not a permit until
AUTHORIZES PP
ONLY THE signed by the Building Official or his
WORK NOTED Deputy; and fees are paid, and receipt is
INSPECTION acknowledged in space provided.
DEPARTMENT
CITY OF OFFI AL'S SIGNATURE DATE
EDMONDS�'�/
771.3202 'RELEASED BY: DATE
ORIGINAL
— File
YELLOW
— Inspector
PINK —
Owner
GOLD —
Assessor
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DATION
HECKED BY TYPE OF CO Is RUCTION
CODE HEIGHT
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iPECAREA OCCUPANCY
IALINSPECTOR OCCUPANT
1EOUIRED GROUP LOAD
❑ YES ❑ NO
1EMARKS
FINAL APPROVAL GIVEN BY:
Initi^ils Date
]Building_�� ..
Fire D•e�;t.
Planning (i1:B) VALUATION FEE
Engineering `,' I' nr ..y uartu.FF FRAMINV
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FINAL
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