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DATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
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PERMIT EXPIRES I/
PERMIT
NUMBER
JOB 5121APT01
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.PLAT NAMEISUBDIVISION NO
LOT NO
LID NO,
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LID FEE $
PU13LIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApproved [3
RW Permit Required 0
EXISTING PROPOSED
Street use Pe"it Required 13
Inspection Required 13
Sidewalk Required 13
REQUIRED DEDICATION FT
Underground 13
Wring required 0
METER SIZE
LINE SIZE.
NO. OF FIX URES
PRV REQUIRED
YESM NOO
3
RE14ARKS
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY
DATE
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INSPECTION
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COMPLETED I EXEMPT
STATE'LICENSE NUMBER EXPIRATION DATE
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PROPERTY TAX ACCOUNT PARCEL NO.
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NEW RESIDENTIAL PLUMBING / MECH
ADD COMMERCIAL COMPLIANCE OR
ITION MIXED USE CHANGE OF USE
REMODEL MULTIFAMILY SIGN
GRADING FENCE
REPAIR El. CYOS X FT.)
DEMOLISH TANK Ojr;R I?
E:] GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
LOT COVERAGE
ALLOWED PROPOSED
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REQUIRED SETBACKS (FT)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT L/RSIDE REAR
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PARKING 0
REQ*D PROVIDE
LOTAREA
PLANNING REVIEWED BY DAT
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(TYPE OF USE, BUSINESS OR ACTIVITY) IN:
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TYPE OF CONSTRUCTIOW
OCCUPANA
GROUP
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NUMBER
OF
STORIES
NUMBER OF
DWELLING
UNITS I
SPECIAL INSPECTION
REQUIRED C
CONSULTANT
06CUPANT
LOAD
DEXRIBE WORK BE DONE—
REMARKS
GEOTECH REPORT
BY:
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STRUCTURAL DESIGN
BY:
VALUATION
Description
FEE
Description
FEE
-SOURCE
Plan Check
State Surcharge
HEAT
LOTSLOPE%
VESTED DATE
Building Permit
City Surcharge
PLAN CK 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.
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
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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
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 LA Do OF THE STATE OF WASHINGTON RELATING TO
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WORKMEN'S COMPENSM ON IIN*,ENCE AND RCW 18:27.
CALL
FOR INSPECTION
(425
771 -0220-
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
recqN is acknowNdged in space provided.
FICIA S N TURE DATE
GNAT �U I 0 GEN
DATE SIGNED
RE�E*Stj BY DATE
ATTENTIN 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. UBC1091 IBC110 / IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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