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DATE RECEIVED
PERMIT
CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB SUITE/APT#
ADDRESS
OWNER 7,AMEINAME OF BUSINESS C)
4PLAT NAMEISUB DIVISION NO. LOT NO LID NO.
ADDRESS
692:
CITY
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ADDRESS
NAME
ADDRESS
CITY
PROPERTY TAX
NEW
ADDITION
REMODEL
REPAIR
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GARAGE
CARPORT
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ZIP
ZIP
TELEPHONE
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TELEPHONE
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EXPIRATION D
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NO. -
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RESIDENTIAL
COMMERCIAL
E] MIXED USE
11 MULTIFAMILY
GRADING
CYDS
TANK
EiRETAINING
WALL
ROCKERY
; OR ACTIVITY) EXPLAIN
NUMBER OF
NUM13ER
OF DWELLING
STORIES IL + 4 5C UNITS
nFSrRIBE WORK 10 BE UUNE
ILID
FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApproved
RW Pernut Required
Street Use Permit Required
EXISTING ____ PROPOSED
Inspection Required
Sidewalk Required
REQUIRED DEDICATION FT
Underground
Wiring required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES E3 NO [3
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
CBLII�
� ;vv�01<41 ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE W
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CHECKED BY VARIANCE OR CU SHORELINE OR ADB# I INSPECTION SEPA
REO'D COMPLETED EXEMPT
13YES E3 NO I
CA# ZONE SIGN AREA HEIGHT
WAIVERM ALLOWED PROPOSED ALLOWED PROPOSED
STUDY 13
PLUMBING / MECH LOT.COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR _I FRONT URSIDE REAR 0
COMPLIANCE OR z
z
CHANGE OF USE z
PARKING LOT AREA PLANNING REVIEWED BY DATE
SIGN REO'D PROVIDED
FENCE I
( X FT.) REMARKS
OTHER
FIRE SPRINKLER
FIREALARM
SPECIAL INSPECTION
REQUIRED 13YES
REMARKS
GEOTECH REPORT
BY:
STRUCTURAL DESIG N
BY:
VALUATION
Description
Plan Check
HEAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
PLAN CHECK NO:
Plumbing
Mechanical
2
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 19.00.005A)(5)
PERMIT LIMIT. SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
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*APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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4 ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
a DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
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Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
IS CORRECT: AND TH I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
CONSULTANT
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE I-jillirliliOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
trunowmFiki-9 COMPENPAPrioN INSURANCE AND RCW 18:27.
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DATE SIGNED 425)
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A-VE E; I
IT It LIN OCCUPY A BUILDING OR STRUCTURE UNTIL
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U� BEEN MADE AND APPROVAL OR A CERTI-
A FINAL INSPECTTION ORIGINAL
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC1109 / IBC110 if IRC110. PINK
10104 PRESS HARD - YOU ARE MAKING 4 COPIE
FEE
OCCUPANT
GROUP
LOAD
D escription FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Arnt. Due
1 Receipt #
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.
OFFICIALS SIGNATURE DATE
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