20000974.pdfI DATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
3WNERNAMUNAME OF BUSINE S
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MAILING ADdRESS
CITY ZIP ITELIPHONE
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NAME
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NAME
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ADDRESS
PERMIT EXPIRES J�
US' PERMIT
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NUMBER Zap,?a
7oB SUITE/APTN
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PIT NAMEISUBDIVI$ION -0 LOT NO LID NO.
LID FEE I
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EXISTING — PROPOSED�
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REQUIRED DEDICATION� FT
FIXTURES PRV REQUIRED
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REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
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CITY
17ELEPHONE
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'TATE LICENSE NUM55R E.11HA. 1.N DATE L-1—
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BE DONE
REMARKS
PpnrRFSS INSPECTIONS PER UBC 1081FINAL INSPECTION REO
PLAN CHECK FEE
HEAT SOURCE Gi_AlING% LOT SLOPE I
BUILDING
PLAN 1111TEO DATE
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THiSUPERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPeRTY ONLY. ANY CONSTR CTIONON THE PUBLIC
GRADING)FILL
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES. ETC.) WILL REGUIRE
SEPARATE PERMISSION.
URCHARG
PE MIT APPLICATION: 18. DAIS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG, REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
;APPLICANT
N INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
FROM A Y AND
N
LANDSCAP NG
I EDIlON%WAS'lINGTOl Tg011ICIALS. EMPLOYEES. AND AGENTS
ALL."M '. DAMA.E��. HATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
INSPECTION FEE
I FROM TH,,SUANCl OF THIS PER. I SELANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
WAIVE ORREDUCEANY EOUIREMENT OF ANY CITY RDINANC
.EE.'GTo..GFY R E
0
NOR UMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ROINANCEPROVISION'
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVTE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN 11 CORRECT AND THAT I AM HE OWNER, OR THE DULY AUTHORIZED AGENT F -
CONSTRUC
THE OWNER. I A.RjE To COMPLY WITH CITY AND STATE LAWS REGULATING
NO PERSON WILL BE EMPLOYED
CALL
TION: AND ll� DOING THE WORK AUTHORIZED THEREBY.
CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTII
IN VIOLATION OF THE LABOR
WORKMEN SCOMPENEATION INSURANCE AND RCW 16.27.
Sl:= A�T E SIGNED
(425)
771-0220
7_7EWIOi7
A
EXTf333
IT IS LINLAWFU��O USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
VALUATION I FEE
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