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CITY OF EDMONDS
PERMIT
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CONSTRUCTION PERMIT APPLICATION
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ADDRESS 6-0-1
OWNER NAMEINAME OF BUSINESS
PLAT NAME/SUB DIVISION NO.
LID NO
LID FEE $
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Requirm E3
EXISTING PROPOSED
Street Use Permit Required 13
inspection Requilfid 0
CITY ZIP
TELEPHONE
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REQUIRED DEDICATION FT
Sidewalk Required E3
underground 13
Waing ffiquitod 13
NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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REMARKS
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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HEAT SOURCE
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V STED DATE
Building Permit
City Surcharge
PLAN CHECK NO- 0
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
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DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
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PERMIT APPLICATION: SEE ECDC 19.00,005(A)(5)
91.
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
Fire Review
Plan Chk. Deposit
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IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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Total Amt. Due
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CIT Y ORDINANCE
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NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.,
Recording Fee
Rec ipt #
APPLICATION APPROVAL
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
This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC.
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
CALL Building Official or his/har Deputy, and Fees ate paid, and
IN VIOLAT!ON OF THE LABQ&CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN S COMPENSATIf INI R
___��ANCE AND RCW 18:27.
OFFICIALS SIGNATUF DATE
(425)
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DATEPIGNEP
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771-0220 �—ELEFED
BY ATEI
EXT. 1333
ATTENTIONVII f
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
ORIGINAL -F UEELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109 I IBC110 / IRC110.
PINK -OW -R - OLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMOTO: PERMIT COORDINATOR, BUILDINGPIVISION
FROM: FIREDEPARTMENT DATE
PLEASE SIGN
ENGINEERING DIVISION DATE
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A field inspection was conducted to . determine compliance with approved plans. Final approval.
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denotes that there are no objections from the above signed Department to the. release of
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P ERFORMANCE BONDS and the granting of:
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
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Copy of CONDITIONS given to owner/contractor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
'Copy of CORRECTION NOTICE given to owner/contractor by inpector
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RE -INSPECTED OUTSTANDING ISSUES 7 GRANT FINAL PROJECT APPROVAL
Date Si 9 n ature
1:temp:b1dg:formS:ocaprv1 3i25/04