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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEiNAME OF BUSINESS
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=1 MAILING ADDRESS
ITELEPHONE
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PERMIT EXPIRES
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ONLY. ANY CONSTRUCTIO P.UOL.IC
BE DONE ON PRIVATE PROPERTY
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2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MAROUEES, ET 'LL.. U, E
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SEPARATE PERMISSION,
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F. PERMIT LIMIT. I AR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
YE
NG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
;A PLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AN. SUCCESORS
FEND AND HOLD HARMLESS THE CITY OF
AGREES TO:ND0EMN1CFjy�LDE
ENG, INSPECTION FEE
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2 EDMOND$. WASHINGTON, TS P YEES AND
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OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
RECE�;;
FROM , . ANCE 0 THIS PERMIT, ISSUANCE
DEEMED MODIFY WAIVEOR REDUCEANY REOURREMENTOF ANYCITY ORDINANCE
To
ANYORDMANCE PROVISION,'
RED
NORLIMI TINANYWAYTHE CITY'S ABILITY To ENFORCE
TOTAL AMOUNT DUE 3
FO.MNT.N
I . HFN H A I
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPI CEA1 UL1Y THAT T.
APPLICATION APPROVAL
,
GIVEN I PRECT. AND THAT I AM THE OWNEK OD T. G AUTH. I EGA E TOF -
S DO CONSTRUC
THEOWNER I AGREE TO COMPLY WIT. CITY AND STATE LAWS REGULATILNG
BE EMPLOYED,
CALL 516,11og Officlot Dopoty%ld Fool 11. Paid.
TION, AND, IN DOING THE WORK AUTHORIZED THEREBY. N PERSON YoL
OF WASHINGTON RELATING T
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FOR INSPECTION
IN VIOLAT ON OF THE LABOR CODE OF TH E STATE
- COMPENSATI 9CE AND RCW 18-27
OFFICIALS SIGNATURE DATE
WORKMC
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771-0220 ASED DATE
EXT 333 1 '1
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IT IS UNLAWFULTO USE OR OCCUPY ABUIIDING 08 STRUCTURE UNTIL 771-0221
FINAL INSPECTION HAS BEEN MADE AND APPROVAL 08 A CERTIFI-
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GOLO-ASSESSOR
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CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109
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FINAL PROJECT APPRO-VAL F
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DATE
MEMOTO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE —
ENGINEERING DIVISION DATE —
PLANNING DIVISIONDATE-3�/-0— �w
PROJECT
SITE ADDRESS
PERIAT # ADB#j�-_ 4 _DATE INSPECTED__5Z_?-,_z —-
DESCRIPTION OF WORK 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 granting, of
Final approval of the described work
__�Z_GRANT FINAL PROJECT APPROVAL
—GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
FAILED FINAL INSPECTION OUTSTANDING ISSUES
2.
3.
___RE -INSPECTED, OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
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SETBACKS ....................
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SHEETROCK NAILING
SPECIAL INSPECTION
MISCELLANEOUS ..........
FINAL APPROVAL FOR
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OCCUPANCY
----------------
�DATE RECEIVED
FKRMIT EXPIRE
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CITY OF EDMONDS t,
CONSTRUCTION PERMIT APPLICATION' JOB 11IT111 9L
ADDRESS C711 Al U7 R&
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VESTED DATE
5CHANICAL
PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK 11
'HIS .. E . PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
BE R ) WILL REQUIRE
DOMAIN (CUR SIDEWALKS, DRIVEWAYS, QUEES, ETC.
GRAPIHG�
JJAI I.AAJ.-
STATE SURCHARGE
,
PEPM,MA
SEPARATE SStONL
MIT APPLICATIO � 100 DAYS
PERMIT �IMIT. I YEAPIE." PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ENO. REVIEW FEES
ENG. INSPECTION FEE
;APP LIEC�A�N.TjCAJ.l Eil�tLF 0 1 H I El OR HER S 1. U S E. H El R S. ASSiiCl NS AN D SUCC E SO A S
NT R _ TO,.. ARMLESS THE CITY OF
N MNIFY, DEFEND AND HOLD H
m EDMONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
IF OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
AD IT SHALL NOT BE
ALL CLA %'1FO1UI 'A'�AME OF"1111. PEP.11 ISSUANCE OF THIS
F PERM
"M T " Y Y
OR REDUCE ANY REOUIREMENTOF AN IT ORDINANCE
09EMEDTOMODIFY. WAIVE TY'S ABILITY TO ENFORCE ANY ORDINAN
0 NOR LIMIT IN ANY WAYTHE Cl CE PROVISION,'
LANR8e-Ptb?G
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PLAN CH CK DEPOSIT
TOTAL AMOUNT DUE
RECEIPT
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INSPECTION
APPLICATION
Thim IPPICRIlOu H,—
Bulld,,,
APPROVAL
p—it until ,igbod by
d:lbu,lu :,it Fu.. n1b P .112.
, — pub,idad.
I HE85BY ACKNOWLEDGE THAT I HAVE READ THIS AIPLICATIUN� THAT THE I'N.10"MATION
R G AUTHOR' AGENT OF
T'E
GIVEN IS IRRECT; AND THAT I AM TffC0W%R6 OT
THE OWN CC I AGR,,,o COMPLY H ITYA S ATE LAWS REGULATING CONSTRUC
'ER .IN. THE WORK AU�IT
TION AN. ll� HORIZED THEREBY. NO PERSON WILL BE EMPLOYED
TO
IN VJ'6LATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING I DATE
WORK5N:QCOMPENSATIO SURANCE AND POW 18.27. OFFICIALS SIGNATURE
�,6�JU�fi �V� --T- (425)
,/DWNPOCA17ETT��,-) -
77 DA
771-0220 DATE
EXT 333
ATTENTIO; LME UNTIL
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCT 771-0221
A Fi AL NSPECTION HAS BEEN MADE AND APPROVAL OR ACERTIFI- ORIGINAL � FILE YELLOW, INSPECTOR
N I PINK - OWNER GOLD � ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX