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CONSTRUCTION PERMIT APPLICATION do8 ADDRESS
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OWNER NAME/NAME OF BU/)pSINESS J/ ' I �f / ( /
PLAT NAME/SUBDIVISION NO. LOT LID NO.
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW PerApproved
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C , Hei - 1 Street Use Permit Req'd []
CITY VZIP TELEPHONE EXISTING PROPOSED inspection Required Q
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O IIS '/� `� d2 REQUIRED DEDICATION FT Wiring required Q
NAME U' II ilii 7 U !'t/ (•. ` / METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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uV OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED 8 RE 'D POSTED
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PROPERTY TAX C RC L NO., COMPLETE EXEMPT ALLOWED PRROPIO ED ALLOWED PROPOSED
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ADDITION COMPLIANCE OR
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PARKING LOT AREA P NG REVI ED DATE a
❑ REMODEL ❑ MULTIFAMILY Er SIGN REO'D PROVIDED
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❑ DEMOLISH ❑ TANK ElOTHER
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NUMBER NUMBER OF CRITICAL
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M OF DWELLING AREAS SPECIAL INSPECTION JAREA OCCUPANT
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PROGRESS INSPECTIONSPERUBC108/IBC109/IRC109FINAL INSPECTION REO'D 9
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VALUATION
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Description FEE Description FEE
Plan Check / State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit City Surcharge S
PLAN CHECK NO: ^ VESTED DATE Plumbing Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC Gradin
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g
SEPARATE PERMISSION.
Engr, Review
PERMIT APPLICATION: 180 DAYS
a PERMIT LIMIT. t YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION WEE
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS 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 Fire 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 p Landsca a Ins Total Amt. Due
9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE p'
=NOR LIMIT IN ANY WAY THE CITY S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt N
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- CALLThis application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO. PERSON WILL BE EMPLOYED Building Official or his/her Deputy: and Fees are paid, and
IN VIDLAT HE LABOR CODE OF THE STATE OF WASHINGTON RELATING To FOR INSPECTION receipt is acknowledged In space provided.
WO 'S COMP
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OF IC S SIGNATU DTE
S NATUR WIVE 1 GEN DATE SIGNED (425)
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ATTENTION !/ II EXT 1333 M J
ITIS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILA FINAL \
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OFOCCU- ORIGINAL - FILE YELLOW -INSPE OR
FANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER GOLD -ASSES OR
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