20050047.pdfrTATE RECEIVED
CITY OF PEDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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ADDRESS
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NAME CBL#
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ADDRESS
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CITY ZIP TELEPHONE
STATR'LICENSE NUMBER EXPIRATION DATE CqatJ iE C K E�D J �3Y
TAX ACCOUNT PARCEL NO.
NEW
RESIDENTIAL
ADDITION
COMMERCIAL
MIXED USE
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
oGARAGE
RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
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OTHER
FIRE SPRINKLER
FIRE ALARM
NUMBER NUMBER OF
OF DWELLING
PERMIT
NUMBER
JOB
ADDRESS
PERMIT EXPIRES
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PLAT NAME/SUBDIVISION NO.
LOT NO
LID NO
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LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Requited
Strew Use Pernut Requited
EXISTING PROPOSED
inspection Requited
Sidewalk Required
REQUIRED DEDICATION FT
Underground
Mono requited
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIPED
YES13 NO13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
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LOT COVERAGE REQUIRED SETBACKS (FT.) PROP SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRON R SIDE REAR
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REMARKS
CONSULTANT
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REQUIRED
DESCRIBE WORK Td"BE DONE
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Description
FEE
Description
FEE
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Plan Check
State Surcharge
HEAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO-
Plumbing
Base F
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Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
Grading
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, 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
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FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY URDINANCE
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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 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THY?VORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
CALL
Building Official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF TH ABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt is acknowledged in space provided.
WORKMEN'S ION INSURANCE AND RCW 18:27.
COMPEX
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OFFICIALS SIGNATURE D TE
NAT REn(ORKAG5NY):
DATE SIGNED
(425)
(s).
71
771-0220
DATE
Y/
ATTENTION EXT. 1333
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. UBC109 if IBC110 / IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL -FILE YEL - INSFIECTC
PINK - OWNER GO ASSESSOR
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