20050408 (2).pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
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LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved O
RW Permit Required o
Street Use Permit Required 0
EXISTING PROPOSED ___ Inspection Required O
Srdowalk Requaed 0
REQUIRED DEDICATION FT Underground O
Wiring required C
METER SIZE LINE SIZE NC. OF FIXTURES PRV REQUIRED
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❑ADDITION MIXED USE CHANGE OF USE z
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❑ REMODEL ❑ MULTIFAMILY ❑ SIGN REQ'D PROVIDED
❑GRADING FENCE
❑ CYDS ( X FT.) REMARKS
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NUMBER NUMBER OF
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Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Gradin
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE g'
SEPARATE PERMISSION.
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
0 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk, Deposit
W IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
f 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 j J�
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscape Insp. Total Amt. Due u t 6
01 NOR LIMIT IN ANY WAY THE CITY'S ABILITY 100 ENFORCE ANY ORDINANCE PROVISION.* '•
Recording Fee Receipt # lU
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 hislhor Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE L R CODE OF THE TATE OF WASHINGTON RELATING TO FOR INSPECTION r eipl is acknowledged space provided.
WORKMEN'S COMPENSATIO URANCE AND RC 16:27. FFIC S S NA _ ATE
SIGNATURE (OWNER AGETp DATE SIGNED (425)
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771 1 =0220 RELEASED Y DATE
ATTENTIO 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 - FILF YELLOW • INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC1091 IBC1101 IRC1109 PINK -OWNER GOLD • ASSESSOR
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