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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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UM MAILING ADDRESS
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CITY ZIP
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NAME
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ADDRESS
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CITY ZIP
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NAME
ADDRESS
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CITY ZIP
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TELEPHONE
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STATE LICENSE NUMBER E:
02125
4C PROPERTY TAX ACCOUNT PARCEL NO.
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ADDITION COMMERCIAL
REMODEL MeOMULTIFAMILY
REPAIR GRADING CYDS
DEMOLISH TANK
GARAGE RETAINING WALL
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[TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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HEAT SOURCE GLAZING %
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CBL #
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DATE I CHECKED BY
PLUMBING / MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
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OTHER
FIRE SPRINKLER
FIRE ALARM
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PERMIT EXPIRES
IUSE PERMIT
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ADDRESS
PLAT NAME/SUBDIVISION NO. LOT NO.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
METER SIZE I LINE SIZE I NO, OF FIXTURES
SUITE/APT#
LID NO.
LID FEE $
7ESCP Approv0d
E3
RW Permit Roquired
13
Street Use Permit Raq'd
13
Inspection Roquifod
(3
Sidewalk Required
13
Underground
Wiring triquired
[3
PRV REQUIRED
YES 13 NO E3
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
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INSPECTION
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SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
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EXP
LOT COVERAGE
REQUIRED SETBACKS (FT)
PROPOSED SETBACKS (F-r.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT L/R SIDE REAR
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PARKING
LOT AREA
PLANNING REVIEWED BY D E
REDO I PROVIDED
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REMARKS
CHECKED BY I TYPE OF CONSTRUCTION CODE OCCUPAN,5
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PROGRESS INSPECTIONS PER UBC 108/IBC109/IRC109 FINAL INSPECTION REQ'D
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LOT SLOPE %
PLAN CHECK NP: VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE'W&K NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
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IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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< ALL CLAIMS FOR DAMAGES OF WHATEVER NA1 URE, ARISING DIRECTLY OR INDIREC1 LY
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
2 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
II 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 INSURANCE AND RCW 18.27.
SIGNATUU XW�,R DATE SIGNED
& le-21 126xo�s
A17ENTION "
IT IS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC1 09 / IBC1 10 / IRC1 10.
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
2
CALL
FOR INSPECTION
(425)
771-0220
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
/Total Amt. Due
Receipt #
APPLICATION APPROVAL
I his 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.
OFFICIALS SIGNATURE I DATE
,AEOASED BY DkTE
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
ORIG NAL FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
Pier/Porch .................
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
Rough -In ...................
Commercial Final ......
HEATING:
Gas Test ....................
Gas Piping .................
Equipment .................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST'FLOOR FRAMING...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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