20050540.pdfDATE RECEIVED
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EXPIRES
PERMIT
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CITY OF EDMONDS
PERMIT
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CONSTRUCTION PERMIT APPLICATION
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ADDRESS
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PLAT NAME/SUBDIVISION NO.
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REQUIRED DEDICATION FT
Sidewalk Required
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LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
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ADDITION 1:1 El CHANGE OF USE
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PARKING T AREA G REVIEWED 13Y DATE
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[3 REPAIR 13 CYDS 13 ( X FT.) REMARKS
DEMOLISH TANK 1:1 OTHER
GARAGE RETAINING WALL FIRE SPRINKLER
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Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE LOTSLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: 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 PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
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I= SEPARATE PERMISSION. Engr. Review
1% PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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PERMIT LIMIT: SEE ECDC i9.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) S Fire Review Plan Chk. Deposit
U) APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSOR
Lu IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
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M 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 LandscapeInsp. Total Amt. blue
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINAN
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee Receipt # 17y
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 histher Deputy: and Fees ate paid, and
TION; AND IN DOING THE VOGR4 AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED receipt is acknowledged in space provided
IN VIOLATION OF THE LABOR-'tQDE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
DAT
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WORKMEN'S COMPENS�710� INSU�qNCE AND RCW 18:27.
SIGNA� --71-1
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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 FILE YELLOW - INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC * 110. PINK -OWNER GOLD - ASSESSOR
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Date Signature
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