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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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NAME
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PERMIT EXPIRES
PERMIT
NUMBER
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ADDRESS
PLAT NAME/SUBDIVISION NO.
7T NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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RW Pernist Required
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Street use Permit Requited
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EXISTING PROPOSED
Inspection Required
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SiddWalk Requited
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REQUIRED DEDICATION.
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underground
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METER SIZE LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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INSPECTION
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STATE LICENSE NUMBER
EXPIRATION DATE
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REQ D
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COMPLETED EXEMPT
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ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
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PROPE_%TY TAX ACCOUNT PARCEL NO.
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PROPOSED SETBACKS 'FTA
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CARPORT
(TYPE OF USE. B
NUMBER
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MIXED USE
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PLUMBING / MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACK5 (F 1.)
FRONT SIDE REAR
FRONT URSIDE REAR
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PARKING
REO'D PROVIDED
LOT AREA
PLANNING REVIEWED BY DATE
GRADING
CYDS
FENCE
( X FT.)
REMARKS
TANK
OTHER
RETAINING WALL
ROCKERY
FIRE S PRINKLER
FIREALARM
�j ACTIVITY) EXPLAIN:
NUMBER OF
OF
STORIES
DWELLING
UNITS
�PECIAL INSPECTION
REQUIRED 13YES
DESCRIBE WORK TO BE DONE
REMARKS
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GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
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VALUATION
Description
Plan Check
HEATSOURCE
LOTSLOPE%
VESTED DATE
Building Permit
PLAN CHECK NO:
Plumbing
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
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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
CONSULTANT
FEE
OCCUPANT
GROUP
OCCUPANT
LOAD
Description
State Surcharge
City Surcharge
Base Fee
FEE
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'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
Fire Review
Plan Chk. Deposit
Aj IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
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
I.andscape Insp,
Total Amt. Due
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
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Recording Fee
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Receipt #
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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 pchnit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC.
AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
CALL
Building Official or histher Deputy and Fees are paid, and
TION;
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt is acknowledged in space provided
WORKMEN'S COMPENSATIOt��SURANCE AND RCW 18:27.
OF LS SIGNAT RE DATE
SIGNATU E WNEfli R
DATE SIGNED
(425)
UdEN
771 -022 0
El -AS DfiY DA A
ATTtNTION
EXT. 13;&
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
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ORIGINAL -FILE YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 f IBC110 I IRC110.
PINK -OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
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DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROMe FIRE DEPARTMENT DATE
pLFASE SIGN
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A field inspection was cted to determine flnal compliance with approved plans. Final approval
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Sign
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