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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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NAME
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CITY
STATE LICENSE NUMBER
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EXPIRATION DATE I CHECKED BY
PARCEL NO.
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VESTED DATE
PERMIT
NUMBER
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ADDRES,
PLAT NAMEiSUBDIVISION NO
PERMIT EXPIRES
S ITE/APTP
LOT 140 LID NO
II LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPAppfri�Ld 13
RW Perind Retiwrtrd 0
Street use Permit Required 13
EXISTING PROPOSED- Inspechon Required 13
Sidewalk Required [3
REQUIRED DEDICATION FT Undetq,ound 0
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METER SIZE LINE SIZE NO. OF FIXTURES I PRV REQUIRED
I I YES [3 NOO
REMARKS
OWNERJCONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED 13Y DATE
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REO'D COMPLETED EXEMPT
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ARIAN
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S T DY 13 PROPOSED ALLOWED PROPOSED
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OT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT LIRSIDE REAR
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PARKING LOTAREA PLANNING REVIEWED BY DATE
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PLAN CHECK NO:
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
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 MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITY'S 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 COMPENS�=ANCE AND RCW 18:27.
SIGNATURE (OWNER 0 ;F"N T DATE SIGNED
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OCCUPANT
GROUP
SPECIAL INSPECTION CONSULTANT OCCUPANT
REQUIRED 13YES I I LOAD I
REMARKS
GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recordinci Fee
CALL
FOR INSPECTION
(425)
771-0220
FEE Description
State Surcharge
City Surcharge
Base Fee
FEE
Plan Chk. Deposit
Receipt #
el/
Total Amt. Du
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or lusilher Deputy: and Fees are paid, and
receipt is acknowledged in Space provided
OFFIC 71
JALS T/NTURE 7 DATE
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RELEASED BY" DITE
ATTEN11ON r—A 1. 10a%)
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. LIBC1091 IBC110 / IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
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Pier/Porch ................. 0
Retaining Wall ........... 0
M
Slab Insulation ..........
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PLUMBING:
M
Underaround ............. C
M 0
Rough -In ................... __110
0 C
—4 K
Commercial Final ...... M
M Z
HEATING: 10-1
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Gas Test ....................
3:
Gas Piping .................
0 _n
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Equipment .................
Commercial Final ....... M M
EXTERIOR SHEATHING 0 r-
0 ITI
NAILING .......................... C C/)
Cl)
FRAMING ........................ Q 0
Z
__1
FIRST FLOOR FRAMING ...
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INSULATION ...................
Floor Insulation ......... >
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Wall Insulation ...........
Ceiling Insulation ....... z
0
SHEETROCK NAILING ... I
0
ITI
SPECIAL INSPECTION
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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