20050960.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILINGADDRESS
CITY ZIP TELEPHONE
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NAME
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A I , I PERMIT EXPIRES
PERMIT
NUMBER
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PLAT NAME/SUBOIVISION No.
LOT NO
LID NO,
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApproved
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RIN Permit Required
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EXISTING PROPOSED
Street Use permit Required
Inspection Required
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Sidewalk Required
13
REQUIRED DEDICATION
FT
Underground
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== required
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METER SIZE
LINE SIZE
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PRV REQUIRED
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FIRE REVIEWED BY DATE
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PLANNING REVIEWED 13Y
DATE
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REPAIR
DEMOLISH
GARAGE
CARPORT
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MULTIFAMILY
GRADING
CYDS
TANK
RETAINING WALL
ROCKERY
FENCE
( X FT.)
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FIRE SPRINKLER
FIRE ALARM
REMARKS
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NUMBER
NUMBER OF
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SPECIAL INSPECTION
CONSULTANT
OCCUPANT
STORIES
UNITS
REQUIRED 13YES
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
GEOTECH REPORT
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VALUATION
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Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
LOT SLOPE%
VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO:
Plumbing
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Base Fee
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Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
Grading
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
Engr. Inspection
PERMIT LIMIT: SEE ECDC i9.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) CCESSORS
V) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SU
Fire Review
Plan Chk. Deposit
UJI 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
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
0i DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscapelnsp.
Total Amt. Due I C)
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
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M,
Recording Fee
Receipt # k2
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 CONSTRLIC-
CALL
This application is not a permit until signed by the
TION; AND. IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
Building
Official or hisliter Deputy: and Fees ire paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
recciplAacknowledged in space provided
WORKMEN'S COMPENSATIO NCE AND RCW 18:27.
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SI RE (0 NER Clill(A—aWT): DATE SIGNED
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771.0220 I
RELEASE
DATi
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AT NTION
AT N I N
R 7UPY
EXT. 1333
ULI C A BUILDING OR STRUCTURE UNTIL
IT NLAWFUL TO USE
IT W
A FINAL INSPECTION HWBCEE�N MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. USC109 / IBC110 If IRC110.
ORIGINAL -FILE - YELLOW -INSPECTOR
PINK -OWNER - GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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