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LID FEE S
MAILING ADDRESS
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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EXISTING — PROPOSED
REQUIRED DEDICATION— FT
inspection Requited
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CITY ZIP
TELEPHONE
METER SIZE
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NO. OF FIXTURES
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NAME
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STATE LobENSE NUM13ER
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EXPIRATION A
70
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CARPORT
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ME OF USE, BUSINESS OR ACTN" EXPLAIN:
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REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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PLUMBING / MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT L/RSIDE REAR
EjCOMPLIANCE OR
CHANGE OF USE I I
PARKING LOT AREA PLANNING REVIEWED BY DATE
SIGN REOD PROVIDED
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
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PERMITAPPLICATION: ISO DAYS
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PERMIT UMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
OF
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY
EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
ALL CLAIMS FOR DAMAGES
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 HERESY 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 CONSTRUC-
TION; AND IN DOING THRMORg)RIZED THEREBY, NO PERSON WILL BE EMPLOYED
OD OF THE STATE OF WASHINGTON RELATING TO
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IN VIOLATION OF THE LA
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WORKMEN'S COMPENS. -1 - � CE AND RCW 18.27.
SIGNATURE (OWNER At"AGENT)
DATE SIGNEV
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A-PENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
101
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PECIAL INSPECTOR
EOUIRED [3 YES
MARKS
FALLIATION $
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PER UBC 108/FINAL INSPECTION REQ'O
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Receipt #
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Receipt #
APPLICATION APPF &VAL
CALL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
FOR INSPECTION
receipt Is acknowjopAed In space provided.
DATE
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771-0220
RE SIf1D_BY OFATE
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OWNER NAMENAME OF BUSINESS
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PLAT NAME/SUBDIVISION NO.
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Underground
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CITY ZIP
ITELE PHONE
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NAME
METER SIZE
LINE SIZE I
NO. OF FIXTURES
PRV REQUIRED
YES13 NO 13
ADDRESS
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
CITY
Zip
TELEPHONE
NAME
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ADDRESS
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CITY
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STATE LIbENSE NUMBER
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NEW RESIDENTIAL
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OF
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
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EXP
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[3 PLUMBING / MECH ALLOWED PPe,3POSED �;FRONIT SIDE REAR FRONT LIR SIDE REAR
[3 COMPLIANCE OR
CHANGE OF USE
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VESTED DATE i i Plumbing
FEE
FEE
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Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DOKE ON PRWATE PROPERTY ONLX ANY CONMUCTION ON THE PUBLIC
Grading
Recording Fee
3 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WlLL REQUIRE
SEPARATEPERMISSION.
eview
City Surcharge
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PERMrrAPPucATi6N.'iWDAY'8
PERMIT LIMM I YEAR - PROVIDED W0111K IS STARTED WITHIN 180 DAYS
spection
State Surcharge
SEE 1114ACKOF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Traffic Mitigation
Plan Chk Deposit
IN INTEREST, AGREES TO INDEMNIFX DEFEND AND HOLD HARMLESS THE CITY OF
#
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Review
Receipt
ALL CLAIMS FOR DAMAGES OF WHATEVER MATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PEflMrE ISSUANCE OF THIS PERMIT SHALL NOT BE
Fire Inspection
Total Amount Due
11.'r'.
/
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
—010-le
NOR LIMIT IN ANY WAY THE CITTS ABILITY TO EN FORCE ANY O.RDINANCE PROVISION.'
Receipt #
I
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Landscapelnsp.1
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 CONSTRUC-
CALL
This application Is not a parnilt until signed by the
0
TM. AND IN DOING THE WOR ORLZED THEREBY, NO PERSON WILL BE EMPLOYED
Building 011icial or hlsltw Deputy: and Fees we paid, and
IN VIOLATION OF THE LAD 0 ID, F THE STATE OF WASHINGTON RELATING TO
RIN
FOR INSPECTION
receipt Is 8tcknovwjsf*d In space provided.
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WORKMERS COMPENSAV;W E AND RCW 18.27.
0 ICIALS U DATE
SIGNATURE GENT)
(OWNER
DATE SIGNED
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771 -0220
MATE
RE 8 D BY
ATf&TION
Off 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE - YELLOW - INSkCTO9
CATE OF OCCUPANCY HAS BEEN GRAWED. UBC SECTION 109
FAX
PINK - OWNER - GOLD - ASSESSOR
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