920260.pdfCITY OF EDMONDS
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/ PERMIT
/ NUMBER
CONSTRUCTION PERMIT APPLICATION
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LEGAL DESCRIPTION CHECK SUBDIVISION NO.
LID NO.
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP,
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CITY ZIP TELEPHONE NUMBER
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EXISTING
REQUIRED DEDICATION
RW Permit RIgW
RWet use Required
Permit Required
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NAME
PROPOSED
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Side Walk Required
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NAME
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ENGINEERING MEMO DATED
REVIEW
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METER SIZE DUILDING SUPPLY SIZE NO. OF FIXTURES
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REMARKS
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STATE LICENSE NUMBER
EXPIRATION DATE
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SIGN AREA
SEPA REVIEW
ADS NO,
19-
Legal Description Of Property - Include all easements
ALLOWED PROPOSED COMPLETE
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DATE
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REMARKS
Parcel No.
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ADDITION
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MECHANICAL
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INSPECTORSWIM AREA
GROUPAf�� NCY
OCCUPANT
REQUIRED
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GARAGE
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ASPORT
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RENEWAL
REMARKS
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PROGRESS INSPECTIONS
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VALUATION
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Check No.
MECHANICAL
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This Permit covers work to be done on private property ONLY.
GRADINGIFILL
Any construction on the public domain (curbs, sidewPlks,
driveways, marquees, etc.) will require separate permission.
STATE SURCHARGE
Permit Application: 180 Days
Permit Limit: 1 Year - Provided Work is Started Within 180 Days
STORM DRAINAGE FEE
"Applicant, on behalf of his or her spouse, heirs, assigns and
ENG. INSPECTION FEE
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successors in interest, agrees to indemnify, defend and hold
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harmless the City of Edmonds, Washington, its officials,
aemployees,
and agents from any and all claims for damages of
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whatever nature, arising directly or indirectly from the issuance
PLAN CHECK DEPOSIT
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of this permit. Issuance of this permit shall not be deemed to
modify, waive or reduce any requirement of any city ordinance
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nor limit in any way the City's ability to enforce any ordinance
TOTAL AMOUNT DUE
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provision."
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1 hereby acknowledge that I have read this application; that the
ATTENTION
APPLICATION APPROVAL
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
THIS PERMIT
This application is not a permit until
state laws regulating construction; and in doing the work authoriz•
AUTHORIZES
signed by the Building Official or his/her
ed thereby, no person will be employed in violation of the Labor
ONLY THE
WORK NOTED
Deputy: and fees are paid, and receipt is
Code of the State of Washington relating to Workmen's Compensa•
acknowledged in space provided.
Lion Insurance.
SIGNAq� OWN/ER A GATE SIGNED
INSPECTION
DEPARTMENT
OFFI IAL'S SIG ATURE DATE
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CITY OF
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EDMONDS
ATTE N N
INSPECTION
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
771-0220
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
ORIGINAL - File YELLOW - Inspector
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. UBC
CHAPTER 3.
PINK - Owner GOLD - Asses
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