20050366.pdfDATE RECEIVED
CITY OF EDMON DS
CONSTRUCTION PERMIT APPLICATION
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NAME
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PLAT NAMEISUBDIVISION NO.
LOT NO
LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Required
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Street Use Permit Required
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EXISTING PROPOSED
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Wiring required
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METER SIZE
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0. OF FIXTURES
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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Description
FEE
Description
FEE
Plan Check
State Surcharge
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LOT SLOPE7_____T_VESTED
DATE
Building Permit
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City Surcharge
PLAN CHECK NO:
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Plumbing
Base Fee
Mechanical
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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, D I RIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Grading
Engr. Review
2
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
IL PERMIT LIMIT. SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
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*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.
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
CE Landscapelnsp. Total Amt. Due
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINAN
0 NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION..
Recording Fee Receipt # 07/a
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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_ CALL Building Official or hisihor 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 COMPENSATION INSURANCE AND RCW 18:27. OFFICIALS SIGNATURE DATE
iIii-trl DATE S (425) Lt�
S19NATURE (OWNER OeGkNi) IGNED
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DATE
L 771-0: RELEASECVBY I
1� 220 1
ATTENTION 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.IfFILE - YELLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 I IBC110 / IRC110. PINK -OWNER GOLD - ASSESSOR
10104' PRESS HARD - YOU ARE MAKING 4 COPIES
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