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Ol Street Use Permit Required E3A
CITY TELEPHONE EXISTING PROPOSED inspection Requited
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Description - FEE Description FEE
Plan Check State Surcharge A. 4:�c
HEAT SOURCE LOTSLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO. Plumbing Base Fee
1�60
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO Wo
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Grading
9 DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
t: SEPARATE PERMISSION.
2 - Engr. Review
cc PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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PERMIT LIMIT., SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Fire Review Plan Chk. Deposit
tn NS AND SUCCESSORS
V) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIG
uj IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt # .97514
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
ODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapelnsp. Total Amt. Due
_j DEEMED TO M Y WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
0 NOR LIMIT IN AN
mi Recording Fee Receipt # 9-714
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 This application is not a permit until sigtied 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 FOR INSPECTION receipt is acknowledged in space provided
IN VIOLATION OF THE LABOR CODE OF JJHIE STATE OF WASHINGTON RELATING TO
WORKMENIIS 5P"SATION INS?i�NCKA D RCW 18:27.
FIC A �SSI!1�10A I DATE
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By
SIGNAT E 0 RAGEN DATE SIGNED (425)
771-0220 RELEAS D BY
ATTENTION 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- ORIGINAL -FILE YELLOW - INSPEJOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 if IBC110 f IRC110. PINK -OWNER GOLD ASSESSOR
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Date Signature
1:tCMP:b1dg:fonns:ocaprv1 3/25/04
FINAL PROJECT APPROVAL FORM
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