20030428.pdfDATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit R6qu:rod
EXISTING — PROPOSED
Street Use Perm I R&q'd
inspection Required
Sidewalk Required
REQUIRED DEDICATION— FT
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METER SIZE LINE SIZE NO. OF FIXTURES
PRV R EOUIRED
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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STATE LICENSE NUMBER EXPIRAT19N DAT H BY VARIANCE OR Cu SHORELINE OR AMIN INSPECTION BOND
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LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (Fr.)
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COMPLIANCE OR
ADDITION COMMERCIAL 0 CHANGE OF USE
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PARKINGI LOT AREA PLANNING REVIEWED BY DATE
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REMARKS
DEMOLISH TANK OTHER
GARAGE RETAINING WALL F RE SPRINKLER
CARPORT ROCKERY FIRE ALARM
(TYPE OF USE, BUSINESS OR ACT
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NUMBER, NUMBER OF CRITICAL
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OF DWELLING AREAS
SPECIAL INSPECTION AREA OCCUPANT
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DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REG-0
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Description
FEE Description FEE
Plan Check
State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit
City Surcharge
PLAN CHECK VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
2 Grading
3 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMITAPPUCATION: ISO DAYS
IL PERMIT UMM I YEM - PROVIDED WORK IS STARTED WITHIN I So DAYS Engr. Inspection
SEE 13ACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFX DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
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 MODIFY; WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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Total Amt. Due
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
—
Recording Fee
Receipt #
I HERE13Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
APPLICATION APPROVAL
THE OWNER. I AGREE TO COMPLY WITH C17Y AND STATE LAWS REGULATING CONSTRUC-
CALL
This application Is not a permit until signed by the
TION; AND IN DOING THE WORKAUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
Building Official 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 COMPENSATI!INURANCE AND RCW 18.27.
S INNER E DATE S9NED
25)
OFFICIA�SPIGOATURE DATE-
771-0220
PO
RE—LEAM" I D*E
A'17TENTION
Off 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL -FILE YELLOW- INSPECTOR
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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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
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RE -INSPECTED OUTSTANDING ISSUES GRANT FINAL PROJECT APPROVAL
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