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'I DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
CITY
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NAME
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CITY
NAME
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STATE LICENSE NUMBER
DAYA4.rPHO�
PROPERTY TAX ACCOUNT PA
ZIP TEILEPHONE
E;�6 1 4125-77K-701
ZIP ITELEPHONE
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PERMIT EXPIRES
PERMIT
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NUMBER
JOB
ADDRESS SUITE/APT#
PLAT NAME/SUBDIVISION NO:
LOT NO.
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LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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EXISTING PROPOSED
RW Permit Requited C3
Street Use Permit Requited 13
Inspection Required 13
Sidewalk Required 13
REQUIRED DEDICATION FT
Underground 13
Wiring required E3
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES N 13
-
REMARK or L vent Connectors re —
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ffSPONSIBLE F ION CONTROUDRAI
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ZIP TELEPHONE
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EXPIRATION DATE CHECKED BY
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ADDITION
COMMERCIAL
MIXED USE
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
El
DEMOLISH
TANK
GARAGE
RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE, BUSINESSPR ACTIVITY) EXPLAIN
ENGINEERING REVIEWED BY
FIRE REVIEWED BY
VARIANCE OR SHORELINE OR ADB# I INSPECTION
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DATE
DATE
SEPA
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PLUMBING(�ME�CH
LOT COVERAGE
REQUIRED SET13ACKS (FT)
I PROP'C=tVrI3ACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE. REAR
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COMPLIANCE OR
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CHANGE OF USE
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PARKING
LOTAREA
NG REVIEWED BY DATE
SIGN
REQ'D PROVIDED
EFENCE
] ( X FT.) REMARKS
OTHER
FIRE SPRINKLER
FIREALARM
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TYPE oj�C�ONSTRUCTION
CODE
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OCCUPANT
GROUP V3
NUMBER
OF
STORIES
_FESCRIBE
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NUMBER OF
DWELLING
UNITS I
SPECIAL INSPECTION
REQUIRED
CONSULTANT
OCCUPANT
LOAD
WORK TO BE. DONE
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REMARKS
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GEOTECH REPORT
BY:
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STRUCTURAL DESIGN
BY:
VALUATION
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Description
FEE
Description
FEE
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Plan Check
State Surcharge
HEAT SOURCE
44ft
LOTSLOPE%
VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO:
Plumbing
Base Fee
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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
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
'APPLICANT, 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 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 CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapelnsp.
Total Amt. Due
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 CONSTRLIC-
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 COMPENSATION INSURANCE A 18:27.
1
CALL
FOR INSPECTION
(425)
771-0220
APPLICATION AP13ROVAL
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.
OFFNALS SIGNATURE DATE
,
SIG URE (OWNER _YG,
1
4;L �114?11601 �L 1
DATE SIGNED
4. -
3 -- 7 27 '0
RELEAS�q
DATE
ATT NTION .1 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 / IBC110 / IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
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