20050217.pdfDATE RECEIVED.,
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PERMIT
CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB
I ADDRESS
OWNER NAMEINAME OF BUSINESS 76o
PLAT NAME/SUBDIViSION NO.
MAILING ADDRESS
7 12
CITY TELEPHONE
7 7Y 2-
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NAME
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PERMIT EXPIRES 1— 1
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REQUIRED DEDICATION _ FT
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RW Permit Requited
Street Use Permit Required
Inspection Requited
Sidewalk Required
Underground
Wainq required
XTURES I PRV REQUIRED
on fuol-buvning appliances passing
through unheated spaces. tAill-
ENGINEERING REVIEWED BY
FIRE REVIEWED BY
CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED FY_
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ADDITION COMMERCIAL COMPLIANCE OR
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GRADING FENCE
REPAIR CYDS x FT.)
El DEMOLISH 1:1 TANK OTHER
oGARAGE RETAINING WALL Ei FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
(TYPE OF USE. BUSINESS ACTIVITY) EXPLf 11�1:
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OF DWELLING
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DESCRIBE WORK TO BE DONE
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LZA Description
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HEAT S�URCE U LOTSLOPE% ___7EST ED DATE Building . Permit
PLAN CHECK NO: Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Grading
DONMAIN (CURBS, SIDEWALKS. DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
(n 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review
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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 Fire Inspection
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14 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 Landscapelnsp.
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee
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 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC. CALL
TION; AND IN DOING I HE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S COMPENS NSURANCE AND RCW 10:27.
SIG T 14E (OWNER CIA0,1116 DATE SIGNED (425)
771-0220
ATTE14TION r. A I . 1 J -3 -3
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBCIiO / IRC1110.
OCCUPANT
GROUP
OCCUPANT
LOAD
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FEE Description FEE
State Surcharge
City Surcharge /5'.00
,00 Base Fee ;oc), 0
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Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy and Feesare paid. and
receipt is acknowledged in space provided
OFFICJ,ALS SIGNAT DATE
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RELEASED [IN 'N DATE
1,6104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
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