20050935.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
07AME OF BUSINESS
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
PU13LIC RiGliT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Required
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Street Use Permit Floq'd
EXISTING — PROPOSED
inspection Required
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Sidewalk Required
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REQUIRED DEDICATION— FT
Underground
Wiringroquired
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METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL,ORAINAGE
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PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
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VALUATION
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Description
FEE
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Plan Check
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Building Permit
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PLAN CHECICNO: VESTED DATE
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Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
—
Engr. Review
ix
W PERMIT APPLICATION: 180 DAYS
Q-1 PERMIT LIMIT; I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
dAPPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
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 On INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMEDTO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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TotalAmt.Due
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X, NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Fee
Recording
Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
Building Official or his/tier Deputy: and Fees are paid, and
.IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING to
FOR INSPECTION receipt Is acknowledged in space provided.
WORKMEN'S COMPENSATM*44,SURANCE AND RCW 18.271.
017 N RE AT)
SIGNATURE (OWNER OR G�ENT), DATE SIGNED
(425)
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771-0220
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RELEAS(IBY AT
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 CERTIFI-
ORIGINAL - FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
1 PINK - OWNER GOLD - ASSESSOR
Q4/ . 02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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