20050279.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
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CITY ZIP TELEPHONE
NAME
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PERMIT EXPIRES
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REVIEWED BY
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LOT COVERAGE
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REQUIRED SETBACKS (FT.)
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PROPOSED SETBACKS (FT.)
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OCCUPAN
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NUMBER
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NUMBER OF
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SPECIAL IN9PECTION
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DESCRIBE WORK TO BE DONE
REMARKS
GEOTECH REPORT
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VALUATION
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Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOqRqE_
LOT SLOPE7_7
VESTED DATE
Building Permit
City Surcharge
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PLAN ViECK NO:
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT CO - VERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUI31C
60NMAIN (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 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 COMPENSATION IN W 18:27.
CALL
FOR INSPECTION
(425)
771.02,20
APPLICATION,
This application is not a permit until signed by the
Building Official or his/her Deputy: and Foes are paid. and
receipt is acknowledged in space provided.
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Ofll� I IC(ALS 5JQNAT JE DATE
SIGNATURE [077AG ),*:o
DATE SIGNED
D'�Y
DATE
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
PINK -OWNER GOLD - ASSESSOR
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