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. . DATE RECEIVED
CITY OF. EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILINGADDRESS
PERMIT
NUMBER
PERMIT EXPIRES
C65- 654-1
JOB ss SUITE�/T#
ADDRE
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LID FEE S
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING PROPOSED—
REQUIRED DEDICATION FT
TESCP Approved
RW Permit Required 13
Street Use Pamit Required 13
Inspection Required 13
Sidewalk Required 13
Underground 13
Winngrequived .13
CITY ZIP
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TELEPHONE
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NAME
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METER SIZE LINE SIZE OF FIXTURES PRV REQUIRED
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OWN ERIC ONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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STATE LICENSE NUMBER EXPIRATION DATE
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WAIVER 13
STUDY 13
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ALLOWED PROPOSED
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NEW RESIDENTIAL PLUMBING I MECH
COMMERCIAL COMPLIANCE OR
ADDITION 13
MIXED USE El CHANGE OF USE
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REPAIR GRADING FENCE
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LOT COVERAGE
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REQUIRED SETBACKS (FT.)
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PROPOSED SETBACKS (FT.)
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REMARKS
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NUMBER
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NUMBER OF
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GEOTECH R EPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
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Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
LOTSLOPE%
ESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
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
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'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
Fire Review
Plan Chk. beposit
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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 Inspection
Receipt #
LandscapeInsp.
Total Amt. Due
L otal
Recording Fee
Receipt #
R.
121
APPLICATION APPROVAL
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
This application is not a permit until signed by the
CALL Building Official or his/her Deputy- and Fees ate paid. and
FOR INSPECTION rectupt is acknowledged in space provided
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SIGN URk( NE jlli�UA T
DATE SIGNED
ATTENTfOlIf
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 I IBC110 / IRC110-
ORIGINAL -FILE - YELLOW -INSPECTOR
PINK - OWNER - GOLD - ASSFSSOR
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