20051056.pdfFDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME7 13USINESS
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CITY ZIP TELEPHONE
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NAME
tPERMIT
NUMBER
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ADDRESS
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LAT NAME /SUBDIVISION N7
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LOT NO LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApproved
RW Permit RequtrDd
Street Use Permit Required
EXISTING PROPOSED
inspection Requited
Sidewalk Required
REQUIRED DEDICATION FT
Underground
Woring required
METER SIZE
LINE SIZE
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NO. OF FIXTURES
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PRV REQUIRED
YESO NOO
ADDRESS
REMARKS I I � ' �
OWNERiCONTRACTORRESPONt;iY�5�g.R 0 10� T�94D
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CITY ZIP
TELEPHONE
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NAME
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ENGINEERING REVIEWED BY DATE.
ADDRESS
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CITY ZIP
TELEPHONE
STATE LICENSE
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PROPERTYTAX
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ADDITION
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REPAIR
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GARAGE
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MIXED USE
CHANGE OF USE
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NUMBER OF
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DESCRIBE WORK TO BE DONE
REMARKS
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GEOTECH REPORT
BY:
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STRUCTURAL DESIGN
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VALUATIOW'
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UDescription
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Plan Check ___7
HEAT SOURCE
LVSLO . PE� VESTED DATE
Building Permit
PLAII�kHECK NO:
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Grading
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
6APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Fire Review
Fire Inspection
Landscapelnsp.
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
OCCUPANT
GROUP
CONSULTANT OCCUPANT
I LOAD
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL
TION: AND IN DOING THE, WORK AUTHORIZED THEREBY, NO PERSON WILL BE.EMPLOYED
IN VIOLATION OF THE LABOJJAODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S COMPENSAIJOW71%4JRANCE AND RCW 18:27.
ATTEN
IT IS UNLA
A FINAL I
FICATE Of
10104
DATE S NED (425)
7/ 771-0220
EXT. 1333
FEE Description
State Surcharge
City Surcharge
Base Fee
It
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a perinit until signed by the
Building Official or his/her Deputy: and Foes are paid. and
receipt is acknowledged in space provided
URE DATE
" - , I i, �- ( U �()t
�LEASEI) ft \^J I DATE
. TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
CTION HAS BEEN MADE AND APPROVAL OR A CERTI-
ORIGINAL - FILE YELLOW - INSPECTOR
UPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK - OWNER GOLD - ASSESSOR
PRESS HARD - YOU ARE MAKING 4 COPIES
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