20050239.pdfDATE RECEIVED I i* rA -
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PERMIT
CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB
ADDRESS
OWNFR NAMEINAME OF BUSINESS
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FIRE SPRINKLER
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FIRE ALARM
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NUMBER OF
DWELLING
UNITS
PERMIT EXPIRES
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SUITE/APT#j
LOT NO
PU13LIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING PROPOSED
REQUIRED DEDICATION FT
METER SIZE I LINE SIZE NO, OF FIXTURES
REMARKS
OWNER/CONTRACTOR RESPONS113LE FOR
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Street Use Pamir Required
Inspection Required
Sidewalk Required
Underground
Mind reouirod
PRV REQUIRED
YES 13 NO13
SHUrOFF
DATE
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SHORELINE OR ADB# INSPECTION SEPA
REO'D CoMPLETED EXEMPT
13 YES 13 NO
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Description
Plan Check
HEAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
PLAN CHECK NO:
P I lumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS. DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Grading
Engr, Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT. SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
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 CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Fire Review
Fire Inspection
Landscapelnsp.
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
CODE
CONSULTANT
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL
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
WORKMEN'S,�?MPENSATION INSURANCE AND RCW 18:27.
SIGNATU NE 0 DATE SIGNED (425)
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OCCUPANT
LOAD
Description
State Surcharge
City Surcharge
Base Fee
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APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or hislhLr Deputy: and Fees are paid, and
receipt is acknowledged in space provided
FICIALSDATIURE DATE
LE�hEL'ABY I DATE
"ATTENTION 7% L I JJJ
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 I IBC110 / IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
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