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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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Description
FEE
Plan Check
HEAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
PLAN CHECK NO:
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. T141S PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC.
Grading
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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
.0 IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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F EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
x ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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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
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NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
Recording Fee
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
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THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC.
CALL
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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 COMPENSATION INSURANCE AND RCW 18:27.
SIGNATURE (OWNER OpIkGENT):
DATE SIGNED
(425)
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771-0220
R ELUE
ATTENTION
EXT. 1333
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTI
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC110 / IRC110.
FICATE
PRESS HARD - YOU ARE MAKING 4
COPIES
10104
OCCUPANTR %�2r
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OCCUPANT
LOAD
Description
State Surcharge
City Surcharge
Base Fee
FEE
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Plan Chk. Deposit
Receipt #
Total Amt. Due
I Receipt # 1_;� 77AI
%PPLICATION APPROVAL
is application is not a permit until signed by the
g Official or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided
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ORIGINAL - FILE YELLOW - INSPECTOR
PINK -OWNER GOLD - ASSESSOR
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