920059.pdfCITY OF EDMONDS LAUUHtSS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
1 • 1 1 / . 1 I j _
PERMIT
NUMBER ' C [�
t SUITE/APT N
LID
LING ADDRESS I
D � PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP. TESCP Approved ❑
Y zip TELEPHONE NUMBER RW Permit Required ❑
�� O EXISTING REQUIRED DEDICATION Street Use Permit Req'd ❑
PROPOSED Inspection Required ❑
AE Sidewalk Required ❑
REMARKS
ADDRESS
CITY ZIP ITELEPHONE NUMBER
ENGINEERING • DATED
D
• , BUILDING NO.
OF
tclo
_�IIIIIIIJELEPHONE NUMBER
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STATE LICENSE NUMBER
__�EPA REVIEW
CHS
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C*15M SIGN AREA
ALLOWED COMPLETE EXEMPT
PROPOSED
Sim
Tax Account Parcel No,
II NEW v M RESIDENTIAL
ElADDIALTER COMMERCIAL
REPAIR APT. BLDG.
GRADING
DEMOLISH CYDS.
CARPORT
REMODEL GARAGE
❑ WOOD STOVE/ ❑ RETAINING WALL/
INSERT ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLI
NUMBER OF STORIES NUMBER OF
I DWELLING
I UNITS
t
' DESCRIBE WORK TO BE DONE (ATTACH PLOT PLAN)
ri
LJ PLUMBING
MECHANICAL
LJ SIGN
FENCE
( x _FT)
QSWIM
POOL.
RENEWAL
EXP
VARIANCE OR CU PLANNING REVIEW BY DATE
SETBACKS -FEET HEIGHT LOT COVERAGE
FRONT SIDE REAR
REMARKS
&�
rREQUIR
L INSPECTOR AREA OCCUPAN Y OCCUPANT
ED GROUP ,LOAD
❑ YES
KSGRESS INSPECTIONS PER UBC 305
U U PLAN CHECK FEE
BUILDING
PLUMBING
Plan Check No. MECHANICAL
This Permit covers work to be done on private property ONLY. GRADINGWILL
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission. STATE SURCHARGE
Permit Application: 180 Days
STORM DRAINAGE FEE
Permit Limit: 1 Year - Provided Work is Started Within 180 Days
"Applicant, on behalf of his or her spouse, heirs, assigns and ENG. INSPECTION FEE
successors in interest, agrees to indemnify, defend and hold
LOU harmless the City of Edmonds, Washington, its officials,
m employees, and agents from any and all claims for damages of
I < whatever nature, arising directly or indirectly from the issuance
M of this permit. Issuance of this permit shall not be deemed to PLAN CHECK DEPOSIT
modify, waive or reduce any requirement of any city ordinance
a: 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. I agree to comply with city and THIS PERMIT
state 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
SIGNATURE (OWNER OR AGENT) DATE SIGNED DEPARTMENT
I CITY OF
EDMONDS
CALL FOR
ATTENTION INSPECTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE 771-3202
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED, UBC
CHAPTER 3.
102.87
a1*
�.a 111
APPLICATION••-•
This application is not a permit until
signed by the Building Official or his/her
Deputy; and fees are paid, and receipt is
acknowledged in space provided.
OFFICIAtjs'JSIGNATUF., DATE
BY: DATE
ORIGINAL
— File
YELLOW
— Inspe
PINK —
Owner
GOLD —
Asset
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