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DATE RECEIVED,
[PERMIT EXPIRES
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CONSTRUCTION PERMIT APPLICATION ADB SUITE/APT# ADDRESS C� L P
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A ` for N A A I t- PLAT NAMEISUBDIVISION NO. LOT NO. LID NO.
UM MAILING ADDRESS t, I I` • v LID FEE 5
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[� .� TESCP Approved
o�J� L_ (� `!' j� PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required
`l ! A 1 \ Street use Permit Required
CITYj, [TEPHONE EXISTING __! PROPOSED _ Inspection Required
C�ZIP 7 n ' ` (�"•• C'/ Sidewalk Required
REQUIRED DEDICATION _ FT Undoirgiound
Worn requited
NAME METER SIZE LINE SIZ7 NO. OF FIXTURES PRV REQUIRED
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ADDRESS REMARKS
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❑ MIXED USE PARKINGLOT AREA PLANNING REVIEWED BY DATE g
13 REMODEL ❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED
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GRADING FENCE REPAIR ❑ CYDS ❑ ( X FT.) REMARKS
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DEMOLISH, ❑ TANK ❑ OTHER
GARAGE Z ❑ CARPORT ❑ ROCKERY IWALL LER
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DescriptionFEE I Description FEE
Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge J
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
t SEPARATE PERMISSION.
Engr. Review
W PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
Q* PERMIT LIMIT: SEE ECDC 19.00,005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Fire Review Plan Chk. Deposit
U) •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS p
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
a 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 Landscape Insp. Total Amt. Due
O NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION,*
Recording Fee Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT 1 AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF This application is not a permit until signed by the
THE OWNER. 1 AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• CALL Building Official or his/her Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION
IN VIOLATION OF THE LABOR CODE OF THE STATE OF.WASHINGTON RELATING TO ; .` receipt is acknowledged in space provided
WORKMEN'S COMPENSATION INSURANCE AND RCW 16:27. )CIALS SIGNATr RE DATE
RE (OWNE SIGNED (425)1W
` I •� ) /�_
-e 771-0220 RELEAS D Y 'L DATE
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 l IBC110 / IRC110. PINK -OWNER • GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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