20050794.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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L) i�vlcc- , llvr 2119t P&C om//_ /7/) -plan Check State Surcharge
HEATSQURCE ILOFI�10P Y, V9S DATI/ Building Permit City Surcharge
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PLAN CHECK NO:
Plumbing Base Fee
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issilPERMIT AUTHORIZES ONLY THE WORI(NOTE;. THIS PERMIT COVERS WORK TO
E DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Grading
M DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
I= SEPARATE PERMISSION.
a Engr. Review
x PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
W
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF'
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
IZ 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 Landscapoinsp. Total Arnt. Due
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee Receipt H
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 OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC - This application is nota permil until signecl by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL [juilding Official or hisitref Duputy and Foosare paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION rortupi ibaCknow1odclod inspact) provided
WORKMEN'S COMPENSAT?!;PVRANCE AND RCW 18:27.
OF F11-JAL S "I' jNjow TF
SIGN (OWNER DATE SIGNED
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.. A T TI( 771-022 Fit I [ AFiLh DY" oAT(
4TTE TION 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- ORIGINAI III I Y(LLOW -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 if IRC110. PINK - OVIINE Ilt - GOI, D - ASSESSOIJ
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