920191.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
CITY ZIP TELEPHONE NUMBER
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NAME
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ADDRESS
CITY ZIP TELEPHONE NUMBER
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STATE LICENSE NUMBER EXPIRATION DATE
Description of Property - include all easements
Property
Tax Account
Parcel No,
NEW RESIDENTIAL
ADDITION COMMERCIAL
REMODEL APT.BLDG.
GRADING
REPAIR CYDS.
DEMOLISH WOODSTOVE
INSERT
❑GARAGE RETAINING WALL/
CARPORT ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER OF STORIES NUMBER OF
DWELLING
UNITS
DESCRIBE WORK TO BE DONE (ATTACH PLOT PLAN)
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JOB
ADDRESS
PERMIT
NUMBER
9 ZO191
36 oul,11011
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)N CHECKI SUBDIVISION NO. ILID NO. �{�f✓�ro
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
EXISTING REQUIRED DEDICATION
PROPOSED
REMARKS
ENGINEERING MEMO DATED
REMARKS
ALLOWED I PROPOSED
VARIANCE OR CU
SETBACKS — FEET
FRONT SIDE
PLUMBING
� MECHANICAL
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LJ SIGN
❑FENCE CHECKED!
( x _FT)
SWIM POOL SPECIAL 11
HOT TUB/SPA REQUIRED
RENEWAL REMARKS
TESCP Approved ❑
RW Permit Required ❑
Street Use Permit Req'd ❑
Inspection Required ❑
Sidewalk Required ❑ 0
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NO. OF FIXTURES
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SEPA REVIEW I ADS N
COMPLETE )EXEMPT
EXP
PLANNING REVIEW BY DATE
HEIGHT I LOT COVERAGE
REAR
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TOR AREA OCCUPANCY OCCUPANT
YES GROUP 9 3 LOAD
PROGRESS INSPECTIONS PER UBC 305
PLAN CHECK FEE
BUILDING
HEAT SOURCE: GLAZING
% PLUMBING
Plan Check No. MECHANICAL
This Permit covers work to be done on private property ONLY. GRADINGIFILL
Any construction on the public domain (curbE, 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
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harmless the City of Edmonds, Washington, its officials,
m employees, and agents from any and all claims for damages of
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whatever nature, arising directly or indirectly from the Issuance PLAN CHECK DEPOSIT
0 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 TOTAL AMOUNT DUE
provision."
I hereby acknowledge that I have read this application; that the ATTENTION
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 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
ti n Insurance. INSPECTION
SIGNATURE (OWNER OR AGENT) GATE SIGNED DEPARTMENT
- CITY OF
EDMONDS
CALL FOR
ATTENTION INSPECTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR 7714220
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED, UBC
CHAPTER 3.
102•S7
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APPLICATION APPROVALAR
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.
ICI 'S SI NATURE UAIt
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cecF v DATE
ORIGINAL — File YELLOW — Inspector U
PINK — Owner GOLD — Assessor v!3/
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