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CITY OFDMONDS
CONSTRUCTION PERMIT APPLICATION
NAME (OR NAME OF BUSINESS)
w MAILING ADDRESS
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NUMBER
NAME
USE
ZONE
ADDRESS
PERMIT
NUMBER
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
EXISTING REQUIRED DEDICATION
PROPOSED
rz
RIGHT OF WAY CONSTRUCTION PERM;PLrQUIRED ❑
STREET USE PERMIT REQUIRED ❑
SEE ENGINEERING MEMO DATE ----------
SEE PIW DEPT. REVIEW CHEC LIST DATED
SUPPLY
CITY TELEPHONE NUMBER
SRE KS
STATE LICENSE NUMBER CITY LICENSE NUMBER
SIGN AREA ENV. REVIEW
ALLOWED PROPOSED COMPLETE EXEMPT
(shoaw below or attach fouer copsinclude all easements
3f s� 3ys�
VARIANCE OR CU PLA NING REVI W BY a
YARDS
FRONT SIDE REAR
LAN NEW
ADD/ALTER
REPAIR
DEMOLISH
RESIDENTIAL PLUMBING
NON-RESIDENTIAL �n MECHANICAL
RETAINING WALL LLB SIGN
❑EXCAVATE
OR FILL
r-1 PRE -MOVE INSP.I
SIDE SEWER EJ WATER LINE
NUMBER OF STORIES NUMRFR OF
UWtLLING
I UNI I,
NATURE OF WORK TO BE DONE (ATTACH PLOT PLAN)
FENCE
( x _FT)
t-1 SWIM
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission.
Permit Application: 180 Days
Permit Limit: 1 Year - Provided Work is Started Within 180 Days
"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 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 construction; and in doing the work authoriz-
ed thereby, no person will be employed in violation of the Labor
Code of the State of Washington relating to Workmen's Compensa-
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SPECIAL INSPECTOR
REQUIRED
, YES t
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
GRADING/FILL
TOTAL AMOUNT DUE
ATTENTION
11 IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
qAPPROVL OR
CERTIFICATENTIL A FINALINOFECOCOCUPANCYHASE DE HAS EN ABEENN GRANTEEDA UBC
CHAPTER 3.
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ATTENTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
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SHORELINE
DATE
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LOAD
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APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or his
Deputy; and fees are paid, and receipt is
acknowledged in space provided.
OFFICIAL'S SIGNATUR I
DATE
/!'
ORIGI L — File/YELL W — Inspector
PINK — Owner GOLD — Assessor
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RECORD OF INSPECTIONS
Date Passed z"
FOUNDATION
t
OVAL GIVEN BY:
FINAL APPP. House
Initials Date Porches, piers
I Retaining walls
Buildin;; _
Fire Dep Garage, carport
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Planning, (ADB) PLUMBING
I ngincering, Underground
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Rough In
Water service
HEATING SYSTEM f"' '
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FRAMING v, ,
WALLBOARD
FINAL 1 4
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