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APPLICATION APPROVAL
1his application i5 not a permit until signed by the
Building Official or his/her Dcputy� and Fees are paid, and
receipt is acknowledged in space provided.
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ATTENTION XT 1333
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL FILE YFLLCW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK - OWNER GOLD ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t HE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
CL PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
(n 'APPLICANI, ON BEHAt F OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
W IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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ALI. CLAIMS FOR DAMAGES OFWHATEVFR NATURE, ARISING DIRECTLYORINDIRECILY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF 1HIS PERMIT SHALL NOT BE
_j DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
01 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
I HEREBY 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 AGHLE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATIONJNSURANCE AND RCW 18,27.
DATE SIG ED
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Plan Check
Building Permit
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VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
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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PERMIT APPLICATION: 1180DAYS ,
PERMIT LIMIT 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
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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 CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
TESCP Approved E3
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required 0
Street Use Permit Roq'd E3
EXISTING - PROPOSED
inspection Required E3
Sidewalk Required
REQUIRED DEDICATION- FT
Underground
Wiring required
METER SIZE
LINE SIZE
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PRV REQUIRED
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ALLOWED PROPOSED
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PROGRESS INSPECTIONS PER UBC 108/FINAL
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VALUATION
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Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
Plumbing
Base Fee
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscape Insp.
Total Amt. Due
Recording Fee
Receipt #
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 permit Until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED Building 011icial or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LA13OR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
OFFICIALS SIGNATURE DATE
SIGNATURE, (OWNER OR AGENT) DATE SIGINED (425) i. 1". 1
771-0220 RELEASED BY DATE
ATTENTION Diff 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CEFITIFI- ORIGINAL - FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK - OWNER GOLD - ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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