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CITY OF EDMONDS NUMBER ca'cllc)lt�_61
CONSTRUCTION PERMIT APPLICATION JOB ITI
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VALUATION
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0"ey (11fA Plan Check State Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge or i
PLAN CHECK NO:
Plumbing Base Fee
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Mechanical 12
L BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
R DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
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I= SEPARATE PERMISSION.
2 Engr. Review
cc PERMIT APPLICATION: SEE ECDC 19.00,005(A)(5)
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PERMIT LIMIT'. SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit
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_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 #
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 ,�&on
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
sommoomcmmomwwm� Recording Fee Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF APPLICATION APPROVAL
THE OWNE IA PLY WITH CITY AND STATE LAWS REGULATING CONSTRUC. This application is not a permit until signed by the
)R CALL Building Official or his/her Deputy: and Fees are paid, and
I� DOGRETE TQW00M
TION; AN[ ING RK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF TH�LABOIR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION It receipt is acknowledged in space provided.
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WORKMEN' TION INSURANCE AND RCW 18:27.
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SIGNATURE I DATE SIGNED I . , 4
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IT IS UNL UL TO E OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL SPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
ri ORIGINAL - FILE - YELLOW - INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 If IRC110. PINK -OWNER GOLD - ASSESSOR
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
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