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STATE LICENSE NUMBER
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RESIDENTIAL
ADDITION
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MULnFAMILY
REPAIR
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DEMOLISH
TANK
GARAGE
CARPORT
RE1AININGW
ROCKERY
ITYPE OF USE. BUSINESS OR A L
NUMBER
NUMBER OF
OF
DWELLING
STORIES
UNITS
DESCRIBE WORK TO BE DONE
i DATE
)NDS
APPLICATION
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PERMIT EXPIRES
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID_ FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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RW Perm" R
Street Use Permit R&qV
EXISTING — PROPOSED
Inspection Required 13
SIdew&* Required 13
REQUIRED DEDICATION— FT
Underwound
Wiring required 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES E3 NO [3 z
REMARKS z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY
FIRE REVIEWED BY
DATE
DATE
FION DATE
V I A N
VARIANCE OR CU
A R
SHORELINEORADBN
I INSPECTION
REQ'D
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AREAS SPECIAL INSPECTION JAREA OCCUPANT
NUMBER REQUIRED [] YES LOAD
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]PROGRESS INSPECTIONS PER UBC IGO/FINAL INSPECTION REO'D 9
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VALUATION
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Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
GLAZING
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%
I . LOT SLOPE %
Building Permit
City Surcharge
PLAN CHECK NO:
THIS PERMIT AUTHORIUMES ONLY THE WORK
BE DONE ON PRIVATE PROPERTY ONLY.
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS,
SEPARATE PtEL4
PERMITAPPLICATI
n
PERMIT LIMM I YEAR - PROVIDED WO
SEE BACK OF PINK PERMIT
VESTED DATE
NOTED. THIS PERMIT COVERS WORK TO
*W CONSTRUCTION ON THE PUBLIC
MARQUEES, ETC.) WILL REQUIRE
M I SSION.
N' 180 DAYS
K IS STARrrED WITHIN 180 DAYS
R MORE INFORMATION
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Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
�212
'APPLICANT, ON BEHALF OF HIS OR HER SP )USE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFY, DEF No AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, E APLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER IN kTURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISWANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANYREQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS ABILITY T) ENFORCE ANY ORDINANCE PROVISION. -
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapeinsp.
Total Amt. Due
Recording Fee
Receint
I HEREBY ACKNOWLEDGE THAT I HAVE READ T Its APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT, AND THAT I AM THE OWN :R. OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY A No STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WORK AUTHORIZED 'HEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLAT;1�0� RELATING TO
ON IpSODE OF THE STATE OF WASHINGTON
COMPE ONINS CE AND RCW 18.27.
COMPE
CALL
FOR INSPECTION
f
(425)
771-0220
"ION APPROVAL
T I !p!P11�al! is not a permit until signed by the
ItilOrilliclitl Ihlsrner Deputy: and F sarepidd,and
,je
receipt Is acknowledged In ep"WrovIded.
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SIGNATURE (OWN4ZpR AGENT)
V_
DATE sIGM,
RELEASED BY bATE
ATTENTION v EXT 1 33
IT IS UNLAWFUL TO USE OR OCCUP� A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN M_�DE AND APPROVAL OR A CERTIFI- ORIGINAL -FILE YELLOW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GR NTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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