20050833.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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PLAT NAM EISU BDIVI SION NO. LOT NO. LiD NO
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PUBLIC RIGH1 OF WAY PER OFFICIAL STREET MAP TESCPApprov E3
RW Pornid ReqViDd E3
Street use Dinnit Required E3
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EXISTING PROPOSED- Inspection Required 13
Sidewalk Required 13
REQUIRED DEDICATION FT undutgfound C3
13
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 13 NOO
REMARKS
OWNER/CONTRACTOR RESPONS113LE FOR EROSION CONTROUDRAINAGE
NAME
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ENGINEERING REVIEWED BY DATE
ADDRESS
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FIRE REVIEWED BY DATE
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Description FEE Description FEE
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Plan Check
State Surcharge
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VESTED DATE
Building Permit
City Surcharge
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PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
a.
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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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 #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
LandscapeInsp.
Total Amt. Due
F FR BE
ROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT CE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINAN
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
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Recording Fee
Receipt
APPLICATION APPROVAL
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
This application is not a permit until signed by the
THE OWNER. I 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
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING To
receipt is acknowledged in space provided
FOR INSPECTION
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
URE DATE
(425) 66c, 19
SIGNAT G6 T
(O��ERO A_,�EJN
DAT E SIGNED
_v DATE
771-0220 —RELENOOD
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ATTENTION
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
I
)FLE YELLOW - INS IECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110.
�YRIGINAL
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PINK - O'V ER GOLD ASSESSOR
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