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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY Z' P TELEPHONE
NAME
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CITY ZIP ITELEPHONE
NAME CEIL It$
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CITY ZIP TELEPHONE
STATE LICENSE NUMBER EXPIRATION DATE
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PROPERTY TAX ACCOUNT PARCEINO. I
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REPAIR
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NUMBER NUMBER OF
OF DWELLING
STORIES Z' I UNITS
DESCRIBE WORK TO BE DONE
HEAT SOURCE
GLAZING %
PLUMBING I MECH
COMPLIANCE OR
HANGE OF USE
SIGN
FENCE
( x FT)
OTHER
FIRE SPRI14KLER
FIRE ALARM
CRITICAL
AREAS
NUMBER
LOT SLOPE %
PLAN CHECK NO: OY I'*'- �� I VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. 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.
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
@APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIF'� DEFEND AND HOLD HARMLESS I HE 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 BF
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE 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 AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRLIC-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE E OF THE S ATE OF WASHINGTON RELATING TO
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WORKMEN'S COMPENSAM��t NCE,6ND RCW 18.27.
SIGNATURq; NER 0 GENT) DATE SIGNED
USE
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JOB
ADDRESS
PLAT NAMEISUBDIVISION NO.
PERMIT EXPIRES
PERMIT
NUMBER 0(1 q
Koll
M/
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
METER SIZE I LINE SIZE I NO. OF FIXTURES
C7_�
SUITE/APT
LID NO.
LID FEE
TESCF7rP'PrVv0d0
Rw Permit Requitea 13
street Lisa permit Req'd 0
inspection Required E3
Sidewalk Required E3
underground
Winng required 0
PRV REQUIRED
YES 11 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION 1. BOND
AEGPI POSTED
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SEPA REVIEW SIGlfjNREA HEIGHT
COMPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROPOSED
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EXP 3af� I A
LOT COVERAGE REQUIRED SETBACKS lFT) PROPOSED SETBACKS (FT)
ALLOWED PROPOSED FRONT SIDE REAR FRONT IJR SIDE REAR
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PARKING LOT AREA PI �JNING REV WE Y DATE
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REMARKS
CHECKED 13Y ITYPSCIM ODE,3 OCCUPANT,,�)
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SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [:] YES LOAD
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PROGRESS INSPECTIONS PER UBC 108 / IBC1 09 if IRCI 09 FINAL INSPEC71ON REO'D I s
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VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
CALL
FOR INSPECTION
(425)
771-0220
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Otlicial or his/her Deputy: and Fees are paid. and
receipt is acknowledged in space provided.
FFIPIfLLS SIGN f� TURE DATE
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FaAcan_ ATE
ATTETION Wk I I ilia
ITISUNI WFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILA FINAL
IN- rTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/IBC110/IRC110.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
ORIGINAL -FILE YEIIJV. INSPECTOR
PINK -OWNER GOLD -ASSESSOR
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
Pier/Porch .................
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
Rough -In ...................
Commercial Final ......
HEATING:
Gas Test ....................
Gas Piping .................
Equipment.................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST FLOOR FRAMING ...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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