920171.pdfM
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CITY OF EDMONDS ZONE
CONSTRUCTION PERMIT APPLICATION joa
OWNER NAME/NAME (F.BUSINESS ADDRESS
NAME
ADDRESS
CITY
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V
ADDRESS
CeIII
STATE LIC
NUMBER
PERMIT
NUMBER
NO.
Z4 PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
P TELEPF ONE NUMBER
EXISTING REQUIRED DEDICATION
PROPOSED
LEPHONE NUMBER
NE N
iption of Property - include all easements
Tax Account Parcel No,
U NEW j►I RESIDENTIAL
ADDIALTER F COMMERCIAL
ElREPAIR APT. BLDG.
GRADING
DEMOLISH CYDS.
CARPORT
REMODEL GARAGE
I�1 WOOD STOVE/ ❑ RETAINING WALL/
INSERT ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLF
NUMBER OF STORIES NUMBER OF
I DWELLING
I UNITS
U PLUMBING
n
� MECHANICAL
ElSIGN
FENCE
I. x _FT)
Swim
POOL
RENEWAL
31 DEjSFRIBE,)/ORK TO BE DONE (ATTACH PLOT PLA�) J
REMARKS
ENGINEERING MEMO DATED
TESCP Approved ❑
RW Permit Required ❑
Street Use Permit Req'd ❑
Inspection Required ❑
Sidewalk Required ❑
REVIEW BY
METER SIZE IBUILDING SUPPLY SIZE I NO. OF FIXTURES
I
I Icc
w
REMARKS a
3
SIGN AREA I SEPA REVIEW I ADB NO.
ALLOWED I PROPOSED COMPLETE IEXEMPT
1 I EXP I I
VARIANCE OR CU PLANNING REVIEW BY DATE
t7
SETBACKS — FEET HEIGHT LOT COVERAGE i
z
FRONT SIDE REAR Z
REMARKS g
;HECKED BY TYPE OF CONSTRUCTION CODE HEIGHT
E-4::�ff
SPECIAL INSPECTOR I AREA OCCUPANCY OCCUPANT
REQUIRED YES I
GROUP k�N� LOAD
PROGRESS INSPECTIONS PER UBC 305 s
J_
7
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FINAL INSPECTION REQUIRED
OPLAN
CHECK FEE
i I
BUILDING
PLUMBING
Plan Chetck NO.
MECHANICAL
GRADINGIFILL
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.
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
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
PLAN CHECK DE OSIT
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.
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 O G NT
DATE SI NED
DEPARTMENT
` CITY OF
Z i� EDMONDS
mm" I
ATTENTION CALL FOR
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
FEE
00,
CX�
APPLICATION APPROVAL
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.
OFFICI S StaNATURE DATE
cr 3-/3'
RELEASED BY: DATE
ORIGINAL —File YELLOW — Inspe9for L
PINK — Owner GOLD — Assessor rb'
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