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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PUBLIC RIGHT OF WAY ER OFFICIAL STREET MAP RW PP Approved7rcil
/ RW Permit Required ❑
Street Use Permit Roq'd ❑
EXISTING PROPO E Inspection Required 13
Sidewalk Required . ❑
REQUIRED DEDICATION ` FT Underground
'wiring required ❑
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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REMARKS i
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWEDBY DATE W
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VARIANCE 0 S INE ORADB# INSPECTION BOND
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A I SIGN AREA HEIGHT
M E EXEMPT ALLOWED . PROPOSED ALLOWE D �'RO� OSED
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OT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS
ALL ED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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ARKING LOT AREA PLANNING REVIEWED BY DATE
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OCCUPANT
GROUM 46
SPECIAL INSPECTION JAREA V OCCUPANT' • _ r
REQUIRED [3 YES LOAD 0
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REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D 9
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<ti C DVL4L o wml0 0 1 , p/ Description FEE Description FEE
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rl Cmacg-, l 04 -Nb � C Building Permit City Surcharge
PLAN CHECK N : t VESTED DATE Plumbing
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Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PE MIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
� DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
I.0 SEPARATE PERMISSION,
Engr. Review
w PERMIT APPLICATION: 180 DAYS
CL PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
to 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
2 IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt a
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
= FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE �-
'9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt, Due
z .NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt N
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- CALLThis application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY• NO PERSON WILL BE EMPLOYED Building Otiicial or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO . FOR INSPECTION receipt is acknowledged In space provided..
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
OFFICIALS SIGNATURE DATE
SI TU\RE WN R AGENT) DATE SGNED �'v3 (425)
C��3�;1 �_�.. L V !/ 7710220RE A BY J 'DATE
ATTENTION EXT 1333
IT IS UNLAWFUL 1'0 USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL -FILE YELLOW -I SP rOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR.
04/02 PRESS HARD-YOU.ARE MAKING 5 COPIES GREEN. ACCOUNTING
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