20050025.pdf—�DATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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OF � DWELLING SPECIAL INSPECTION CONSULTANT OCCUPANT
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VALUATION
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C Description FEE Description FEE
Plan Check State Surcharge
HEAT S �1RCE LOT SLOPE% VESTED DATE
G� Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical r
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION. Engr. Review
Lu PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19,00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Erlgf. InSpeCllOn
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fife Inspection Receipt #
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 Landscape Insp. Total Amt. Due \
z NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.•
Recording Fee Receipt # Q
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 This application Is not a permit until signed by the
THE. OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALLBuilding Official or his/her Deputy: and Fees are paid, and
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 FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATI17NINSURANCE AND RCW 18:27. OFFICIALS SIGNATURE DATE
LA( ER OR OENT►: DATE SIGNED (425,•�Ana/ 7 1 =0220 RELEASED BY ATE
TION EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI• ORIGINAL •FILE YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC1091 IBC1101 IRC110. PINK .OWNER GOLD • ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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