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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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STATE LICENSE NUMBER EXPIRATION DATE CUE124ED BY
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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
'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, EMPLOYEESi 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 ANYCITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
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 OX.THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S 9(gfinKSATION INSURANCEAND RCW 18:27.
DATE SIGNED
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PERMIT EXPIRES
PERMIT
NUMBER
JOB
ADDRESS
SUITE/APTP
PLAT NAMEISUBDIVI SION No. LOT NO, LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Requited
EXISTING PROPOSED
Street Use Pri Required
inspection Required
Sidewalk Required
REQUIRED DEDICATION
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Underground
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Wiring required
METER SIZE
LINE SIZE
PRV REQUIRED
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE
FOR EROSION CONTROL/DRAINAGE
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GEOTECH REPORT
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STRUCTURAL DESIGN
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VALUATION
$ 6-7
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Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
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City Surcharge
Plumbing
Base Fee
Mechanical
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Engr. Review
Engr. Inspection
Fire Review
Plan Chk.. Deposit
Fire Inspection
Receipt #
Landscape Insp.
Total Amt. Due
Recording Fee
Receipt #
APPLICATION APPROVAL
CALL
This application is not apermit until signed by the
Building Official or his/her Deputy* and Fees are paid, and
FOR INSPECTION
receipt is acknowledged in space provided
OFFIQIALS SIGNATURE DAT E
(425)
771 -0220
RE nAT
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ATTENTION V 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 / IRC110.
110104 PRESS HARD - YOU ARE MAKING 4 COPIES
IGINAL -FILE YELLOW - INSP�ECTC
PINK -OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
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MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE-
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DESCRIPTION OF WOP K TO BE INSPECTED
A field inspection was conducted to determine compliance with approved plans. Final approval.
denotes that there are no objections from the above signed Department, to the release of
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PERFORMANCE BONDS and the granting of
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GRANT FINAL PROJECT'APPROVAL
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GRANT PROJECT APPROVAL -WITH CONDITIONS NOTED
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
El Copy of CORRECTION, NOTICE given to owner/contractor by inpector
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RE -INSPECTED OUTSTANDING. ISSUES - GRANT FINAL PROJECT APPROVAL
'Date Signature
1: temp:bldg: forms: ocaprA 3/25/04