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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 ZIP TELEPHONE
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NAME
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NAME I TOM CBL #
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STATE LICENSE NUMBER EXPIIATION DATE CHECKED BY
PROPERTY TAX ACCOUNT PARCEL NO
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ADDITION
REMODEL
REPAIR
DEMOLISH
EGARAGE
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CARPORT
(TYPE OF USE, I
W1 OF
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DRIES
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COMMERCIAL
MULTIFAMILY
GRADING CYDS
TANK
RETAINING WALL
ROCKERY
NUMBER OF
DWELLING
UNITS
TO BE DONE
HEAT SOURCE GLAZING %
PLAN CHECK NO:
PLUMBING / MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
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OTHER
FIRE SPRINKLER
FIRE ALARM
CRITICAL
AREAS
NUMBER Ut—J
LOT SLOPE %
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: 180DAYS
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 INDEMNIFY, DEFEND AND HOLD HARMLESS THE 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 BE
DEEMED TO MODIF4 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 CONSTRUC-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S,COMF.E�SATION INSURANCE AND RCW 18.27.
DATE SIGNED
SIGNATU E (OWNER O� AGENT)
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XPIRES
USE PERMIT
ZONE NUMBER
JOB SUITE/APT#
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PLAT NAME/SUBDIVISION NO. TANO. LID NO.
LID FEE S
TESCP V1110vild 0
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required 13
street use Permit Req'd 13
EXISTING — PROPOSED inspection Required 13
Sidewalk Required E3
Underground
REQUIRED DEDICATION— FT wifing re4upled C3
METER SIZE LINE SIZE OF FIXTURES PRV REQUIRED
YES [3 No 13
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY DATE
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ALLOWED PROPOSED
ALLOWED
PROPOSED
EXP
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LOT COVERAGE
REQUIRED SETBACKS (IT)
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PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
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SPECIAL INSPE9TION AREA OCCUPANT
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1PROGRESS INSPECTIONS PER UBC_108/IBC109/IRC1D9 FINALINSPECTION REO'
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VALUATION
$ 1<2 n.11
Description
FEE
Description
FEE
Plan Check
Building Permit
State Surcharge
City Surcharge
Plumbing
Base Fee
A�2
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review Plan Chk. Deposit
Fire Inspection Receipt #
Landscapelnsp. Total Amt. Due
Recording Fee Receipt #
APPLICATION APPROVAL
This application Is not a permit until signed by the;
CALL Building official or his/her Deputy: and Fees are paid,'and
FOR INSPECTION receipt Is acknowledged in space provided.
FF IALS SIGNATURE DATE
(425)
771-0220 'RE ASED BY /DATE
AT P 10 r.A 1 1%3%3%3 ..1 1 :"/ 1h I 'Ir y /� --I
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
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INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU- ORIGINAL - FILE YELLOW -
PANCY HAS BEEN GRANTED. UBC109/IBC110/iRC110. PINK - OWNER GOLD -
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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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..........................
f Y)3
FRAMING ........................
FIRST FLOOR FRAMING...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
C)
OCCUPANCY ..................
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