20051136.pdfDATE RECEIVED
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CITY OF EDMONDS N MBER
JOB SUITE/APT#
CONSTRUCTION PERMIT APPLICATION �ADDRESS
OWNER NAME/NAME OF BUSINESS e/x
PLAT NAIAE/SUBDIVISION NO LOT NO. LID NO,
LID FEE S
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z PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP 9W Permit Required [3
2.2,1(5- 9 Ob AV Street uso permit Req'd E3
0 Inspection Required E3
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REQUIRED DEDICATIONW/5e Fl underground
66 -7 -N _36/4�0 - T_ wiring required E3
N A�i METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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PLAN CHECK NO- VESTED DATE Plumbing '4� Base Fee
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
2
3 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
2
PERMIT APPLICATION: ISO DAYS
0. PERMIT LIMFP. I YEAR - PROV113ED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Grading
Engr. Review
Engr. Inspection
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Fire Review
Plan Chk. Deposit
APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIG14S AND SUCCESORS
;N INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 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 PERMI1 ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFN� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION"
Fire Inspection
Receipt #
LandscapeInsp.
Total Amt. Due
Recording Fee
Receipt #
CALL
FOR INSPECTION
APPLICATION APPMROVA
This application is not a permit until signed by the
Building Official or hi�*!her Deputy: and Foes are paid, and
receipt Is acknowledged in space provided,
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 NGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
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
—IT" LS SIGN RE DA E
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WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
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771-0220
EXT 1333
SIGNATURE W ER R
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ATTE TION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL F
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL - FILE YELLOW - INSdECTO
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK - OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
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DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
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PLEASESIGN
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Date* Signature
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