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USE PERMIT
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PLAT NAME/S UB DIVISION NO.
LOT NO.
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LID FEE $
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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REQUIRED DEDICATION— FT
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RW Permit Required 13
Street Use Permit Roq'd E3
Inspection Required 13
Sidewalk Required E3
Underground
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NO. OF FIXTURES
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REMARKS
PROGRESS INSPECTIONS PER UBC 108/IBC109/lRC109 FINAL INSPECTION REQ'D
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VALUATION
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Description FEE Description FEE
Plan Check State Surcharge
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HEAT SOURCE GLAZING % LOT SLOPE % Building Permit City Surcharge_
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PLAN CHECK NO: VESTED DATE Plumbing Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
1= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
Engr. Review
lu PERMIT APPILICATION: 180DAYS
91. PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION —1�1
'APPLICANT, 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
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt P
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE Landscapelnsp. Total Amt. Due
DEEMED TO MODIFX WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE L5,5
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x I NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.- Recording Fee 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- This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION _,-_-yceipt Is acknowledged In space provided.
WORKMEN'S COMffAkATIONINSU AND RCW 18.27.
_�,JfIANC L IGNATOFJ DATE
SIG Flit ( WN 0 DATE SIGNED (425) 1
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1 UNLAWFU TO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILA FINAL
INSPECTION HAS BEEN MADE AND APPROVALOR A CERTIFICATE OF OCCU- ORIGINAL - FILE YELLOW - INSPECTOR
PANCY HAS BEEN GRANTED. UBC109/IBC110/IRC110. PINK -OWNER GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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MEMO TO: PERA41T COORDINATOR, BUILDING DIVISION
FRO? FIRE DEPARTMENT DATE,���--�dl
PLEASESIGN
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ENGINEERING DIVISION DATE
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A field inspection was conducted to.determine compliance.with Final approval
approved plans
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denotes that there are no objections from the above signed Department to the release of
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GRANT FINAL PROJECT APPROVAL
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
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El Copy of CONDITIONS given to. owner/contractorby inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE given to owner/contractor by inpector
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:ternp-b1dg:fonns:ocaprv1 3/25/04