20050798.pdfDATE RECEIVED PERMIT EXPIRES
CITY OF EDMONDS
PERMIT
NUMBER
JOB SUITE/APT#
CONSTRUCTION PERMIT APPLICATION
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OWNER NAME/NAME OF BUSINESS
PLAT NAME/SU BDIVI SION NO.
LOT NO
LID NO.
LID FEE S
MAILING ADDRESS
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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RW Permit Requirw 13
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Street Use Permit Required
Inspection Required
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NAME
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REMARKS
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Description
Plan Check
HEAT SOURCE
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VESTED DATE
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Building Permit
PLAN CHECK NO:
Plumbing
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
SEPARATE PERMISSION.
Grading
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Fire Review
Fire Inspection
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ecording Fee
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CONSULTANT
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
GIVEN IS CORRECT.
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRLIC- CALL
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
WORKMEN'S COM PEN SA�191141)*UIRANCE AND RCW 18:27.
SIGNAT AGENT): W411 G N (425)
1 771-0220
LOAD
FEE Description FEE
State Surcharge
f AT City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building official or hisiher Deputy: and Fees are paid, and
receipt is acknowledged in space provided
FI ;SSIGNAT DATE
L17 f/, -
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC1110 / IRC110.
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ORIGINAL -FILE YELLOW -INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
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DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASESIGN
ENGINEERING DIVISION DATE
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PLEASE SIGN
PLANNING DIVISION DATE
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PROJECT 9A-_rW_3
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PERMIT -6 �7 ADB# DATEINSPECTED
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DESCRIPTION OF WORK TO BE INSPECTED
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FAIILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpe.ctor
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:tenip:b1dg:ebrnis:ocaprv1 3/25/04