990823.pdfDATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS II '' ,,
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NAME
ADDRESS
CITY
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ZIP TELEPHONE 2�
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SITE LICENSE NUMBER EXPIRATION DATE CHECKED BY
2 M 20�
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PROPEFITY TAX ACCOUNT PARCEL NO.
❑ NEW ❑ RESIDENTIAL ❑ PLUMBING / MECH
ADDITION { COMMERCIAL COMPLIANCE OR
❑ 11s. ❑ CHANGE OF USE
❑ REMODEL ❑ APARTMENT ❑ SIGN
REPAIRGRADING FENCE
❑ CYDS ❑ ( X FT)
DEMOLISH ❑ TANK ❑ OTHER
❑CARPORT ❑ RETAINING WALL ❑ RENEWAL
z ROCKERY
a(TYPE OF USEJSINESjS OR ACTIVI Y) EXPLAIN:
CRITICAL
w NUMBER NUMBER OF
0 OF - I DWELLING AREAS
o STORIES UNITS NUMBER
DESCRIBE WORK TO BE DONE '
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PERMIT EXPIRES ""- LD
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USE
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NUMBER 3.
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JOB SUITE/APT#
ADDRESS
PLAT NAME/SUBDIVISION NO. LOT NO. '�[� �f LID NO.
—�'-- LID FEE 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Pe Approved
RW Permit Requirele! 'V
Strepl Usd Permit Req'
EXISTING q0 Inspection Required 0
Sdewalk Required ,❑
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REQUIRED FT Vlldng roquned U O
r AOM.,ER`ZE 'r ` ItS F. NO. OF FIXTURES PRV REQUIRED
•,1 f f r YES O NO U ¢
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4;i /CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE E5
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ENGINEERING REVIEWED/DATE f� /
FIRE REVIEWED BY DATE w
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
&fiii I T O REO'D POSTED
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YES �,�
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE I EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
EXP v .,
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR t7
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PARKING LOT AREA PLANNING REVIEWED BY DATE a
REO'D PROVIDED
CHECKED BY
CONSTRUCTIONCO
OCCUPANT
ITYProOF
GROUP
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SPECIAL INSPECTOR
AREA
OCCUPANT
REQUIRED ❑
YES
LOAD
REMARKS
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PROGRESS
INSPECTIONS PER UBC
108/FINAL INSPECTION REVD
5
VALUATION FEE
PLAN CHECK FEE
HEAT SOURCE GLAZING % LOT SLOPE °/ BUILDING too
PLAN CHECK NO: VESTED DATE PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I_ BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC GRADING/FILL
9 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
F SEPARATE PERMISSION.
STATE SURCHARGE
¢ PERMIT APPLICATION: 180 DAYS
wa PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION /,
to "APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS ENG. INSPECTION FEE 5v r_
OcLh 6b
Uj IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF MR llb9exr IQG• , }I
¢ EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND FEE.,'�V d
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY _
= FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE R EIR < 2I CI
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF AN't CITY ORDINANCE PLAN CHECK DEPOSIT L] F
= NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION " RECEIPTO �,'l
'TOTAL AMOUNT DUE I III
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
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 CONSTRUC- (FALLg his application is not it purmd until signed by Tho
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Budding Official or his/hur Doputy and Foos aro paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION rnrmpt is acknowiodgod in apace prowdod.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
OFF! IA rNATI ! GA F�
SIGNA RE (OWNER OR AGENT) DATE SIGNED (425)
H()444 II 0(-tTl 771-0220 71FLWE. BY , DATE
ATTENTION EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771 m0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL •FILE YE LLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION. 109 FAX PINK • OWNER GOLD - ASSESSOR
5/98
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