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PERMIT EXPIRES
CITY OF EDMONDS
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PERMIT
NUMBER
CONSTRUCTION PERMIT APPLICATION
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OWNER N ME OF BUSINESS
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LID NO
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LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL
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STREET MAP
EXISTING PROPOSED
RW Permit Required 0
Street Use Penod Requited [3
Inspection C3
CITY ZIP TELEPHONE
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Sidewalk Required M
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REQUIRED DEDICATION FT
Underground
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NAME
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METER SIZE LINE SIZE NO. OF FIXTURES
PRV REQUIRED
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ADDRESS
REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE
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ELICENSE NUMB!�YZ. 70DATE
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NEW RESIDENTIAL PLUMBING MECH
LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBAC KS (FT.)
COMMERCIAL
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT URSIDE REAR
El ADDITION COMPLIANCE OR
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MIXED USE CHANGE OF USE
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PARKING
LOTAREA
VIEWED BY DATE
MULTIFAMILY
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REPAIR 0 GRADING cyos 1:1
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REMARKS
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GARAGE RETAINING WALL 41RE SPRINKLER
CARPORT
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LOAD
DESCRIBE WORK TO BE DONE
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Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
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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 PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
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
Grading
Engr. Review
Engr. Inspection
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND, SUCCESSORS
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_j IN INTEREST, AGREES TO INDEMNIFY, DEFEVID AND HOLD HARMLESS THE CITY OF
I M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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< ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
Fire Review
Fire Inspection
Plan Chk. Deposit
Receipt #
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.
Landscapeinsp.
Total Amt, Due _:1 -
IP
Recording Fee
Receipt#
1 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 COMPENSATI�WSURANCE AND RCW 18:27.
CALL
FOR INSPECTION
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.
SIGNATURE (OWNER ORl4GENTjj DATE SIGNED
(425)
771-0220
OFFIC LS S N URE kDATE
RELEASED BY DAA
ATTENTION
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 III IRC110. ORIGINAL FILE YELLOW INSPECTOR
PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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