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CONSTRUCTION PERMIT APPLICATION JOB
ADDRESS SUITEJAPTN
OWNER NAMEINA E OF BUSINESS C
PLAT NAMEISUBDIVISION NO. LOT NO. LID NO
M MAILING ADDRESS
or LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApprovea
iii-A 01 cA 0-11,� RW Permit Required E3
Street LISO Perniii Required C3
CITY ZIP TELEPHONE EXISTING PROPOSED Insocclion Required 13
�7 Sidewalk Required , 0
required E3
REQUIRED DEDICATION FT underground
NAME METER! IZC�� -171mr-'=_ f4*+0Rf-&- -iN--aW" OUIRED
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
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PARKIN LOTARE VIEWED BY DATE 5
REMODEL MULTIFAMILY SIGN REO'D PR VIDED (L
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13 REPAIR CYDS ( X FT.) REMARKS
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CARPORT ROCKERY FIRE ALARM
(TYPE OF USE, BUSINESS OR ACT TY ) EXPLAID
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Description FEE Description FEE
Plan Check State Surcharge
HFAT SOUIRCE LOTSLOPE% VESTED DATE
CAS 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
SEPARATE PERMISSION.
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Engr. Review
W
0 1 PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspect ton
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
00 Fire Review Plan Chk. Deposit
W 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
to
_j 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
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapelnsp. Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.' n6—
Recording Receipt # I (q k CIL41
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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. GALL Building Official or his/her Deputy: and Foes 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 COMPENSATI�A�NCE AND RCW `18:27. CIA SI NA DATIt
SIGNATURE (010)PER 0 -AGENT): DATE SIGNED (425)
7 o._15 771-0220
--- RELEASEJY DATq
ATTENTION ' . U EXT. 1333 y
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL L
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m rivijAii- i"arr-ii.,ii IV III NNW jkI 9 ORIGINAL -FILE YELLOW -INSPECTOF
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 I IRC110. PINK -OWNER GOLD ASSESSOR
10104 PRESS HARD YOU ARE MAKING 4 COPIES
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