20050852.pdfFDATE �RECEIVFD
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE
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ADDITION
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REPAIR
DEMOLISH
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CARPORT
(TYPE OF USE, BU
NUMBER
PER141T
NUMBER
JOB
ADDRESS
PLAT NAMEISUBDIVISION NO
PERMIT EXPIRES
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING PROPOSED
REQUIRED
. METER SIZEI f
ENGINEE
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LID NO.
LID FEE S
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RW Parmil Required
5118011 Use Permil Required
Inspuction Required
Sidawak Required
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FIRE REVIEWED BY
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VARIANCE OR CU SHORELINE ORADB11 I INSPECTION SEPA
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ALLOWED PROPOSED
RE RED SETBACKS (FT.
Out
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT URSIDE REAR
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PARKING
REQ'D PROVIDED
LOTAREA
PLANNING REVIEWED BY DATE
GRADING
CYDS
TANK
RETAINING WA LL
ROCKERY
FENCE
( x FT)
OTHER
FIRE SPRINKLER
FIRE ALARM
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REMARKS
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7�LTION
GROUP
NUMBER OF
OF
STORIES
DWELLING
UNITS
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SPEC IALI`NS PECTION
CONSULTANT PANT
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KSCRIBE WORK TO BE DONE I
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REMARKS
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GEOTECH REPORT
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STRUCTURAL DESIGN
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VALUATION
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Description
FEE
Description
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Plan
Check
State Surcharge
H T SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO:
.
Plumbing
Base Fee
A -----------------
Mechanical
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
Grading
SEPARAirE PERMISSION.
Engr. Review
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT. SEE ECDC 19.00.005(A)(6)
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
(n
U) 'APPLICANT, ON BEHALFOF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESSORS
Fire Review
Plan Chk. Deposit
Uj IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
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
Landscapelnsp.
Total Amt. Due
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee
Receipt #
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
.
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-
CALL
This application is not a perind until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
Building Official or his/her Deputy: and Foes are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt is acknowledged in space provided.
WORKMEN'S COMPENSAT!�MRANCIE AND RCW 18:27.
OFFICIALS SIGNATURE ATE
SIGNATURE:7NER O?KGENT):)
DATE SIG
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771-0220
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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- ORIGINAL - FILE YELLOW - INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC11O.. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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