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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PLAT NAMEISUBDIVISION NO.
LOT NO.
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LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Required
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Street use Permit Required
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EXISTING
PROPOSED
inspection Required
Sidewalk Required
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REQUIRED DEDICATION FT
underground
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METER SIZE
LINE SIZE
NO: OF FIXTURES
PRV REQUIRED
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ADDITION
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COMPLIANCE OR
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GRADING
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REMARKS
DEMOLISH
TANK
OTHER
GARAGE
RETAINING WALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIREALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN;
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TYPE PE LICTION
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CODE
OCCUPANT
GROUP
NUMBER
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NUMBER OF
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GEOTECH REPORT
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STRUCTURAL DESIGN
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VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
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.
Grading
Engr. Review
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
Engr. Inspection
OAPPLICANT, 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 A14D
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF T141S PERMIT SHALL NOT BE
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
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Fire Review
Plan Chk. Deposit
715
Fire Inspection
Receipt #
Landscapeinsp.
Total Amt. Due
1 Recording Fee
Receipt #
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 COMPENSATI��NCE AND RCW 18:27.
CALL
FOR INSPECTION
(425)
771-0220
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy. and Fees are paid, and
receipt is acknowledged in space provided.
FFI LS SIGNATARE Dj'E
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SIG RE(O ER NT
DATE S NED
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ATTENTION I=,& L 1,5JJ
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL I II/M
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTi- DRI IN�AL- ILE - YELLOW .4SPEITC
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC110 f IRC1110 PiN -OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
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MEMO'TO- PERMIT COORDINATOR, BUILDING DIVISION.
FROM.. FIRE DEPARTMENT DATE
PLEASF SIGN
ENGINEERING DIVISION DATE
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A field inspection was conducted to determine compliance with -approved. plans. Finalapproval.
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denotes that there, are no objections from the above signed Department to* the release of
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PERFORMANCE BONDS and the granting of..
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GRANT FINAL PROJECT
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..GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
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FAILED FINAL INSPECTION OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE given to owner/contractor by inpector
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:fbrms:ocaprv1 3/25/04