20050053.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAMEOF BUSINESS.
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USE PERMIT
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved E3
RW Permit Required 93
Street Use Permit Roq'd E3
EXISTING PROPOSED
Inspection Required E3
Sidewalk Required El
REQUIRED DEDICATION- FT
Underground
Wiring required 13
METER SIZE
LINE SIZE
RES
PRV REQUIRED
YES 1:1 No E3
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REMARKS
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OWNEFIXONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
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STATE LICENSE NUMBER
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PROPERTY TAX ACCOUNT PARCEL NO.
NEW
RESIDENTIAL
ADDITION
COMMERCIAL
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
GARAGE
RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER
NUMBER OF
OF
DWELLING
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DESCRIBE WORK TO BE DONE
FIRE REVIEWED BY
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SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED
PROPOSED
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PLUMBING / MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (Fr.)
FRONT SIDE REAR
PROPOSED SETBACKS (Fr.)
FRONT LIRSIDE REAR
COMPLIANCE OR
CHANGE OF USE
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PARKING
LOT AREA
PLANNING REVIEWED BY
DATE
SIGN
REQ'D I PROVID ED
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REMARKS
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REMARKS
INSPECTIONS PER UBC 108/ IBC109/IRC109 FINAL INSPECTION REO'D
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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 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 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 COMPENSATIO
,N-LRRANCE AND RCW 18.27.
SIGNATAE (OWNER R DATf ),IGNED
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VALUATION AFFIDAVITS SHALL NOT
BE ACCEPTED
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
Plumbing
Base Fee
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapelnsp.
Total Amt. Due
Ldi
Recording Fee
Receipt #
APPLICATION APPROVAL
CALL
FOR INSPECTION
This application is not a permit until signed by the
Building 011icial or his/her Deputy: and Fees are paid, and
receipt Is acknowledged in space provided.
MI SIG T RE DATE
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771-0220
RELEAStfilAy ,
ATTENTION E)ff 1333
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVALOR A CERTIFICATE OF OCCU- ORIGINAL - FILE YELLOW - INSPECTOR
PANCY HAS BEEN GRANTED. UBC1 09 / IBC1 10 / IRC1 10. PINK - OWNER GOLD - ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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