20051167.pdfDATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
CITY ZIP ITELEPHONE
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DEMOLISH
TANK
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oGARAGE
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NAME�SUBDIVISION NO.
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT)
ALLOWED PROPOSED
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FRONT LIFISIDE REAR
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REMARKS
NUMBER
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STORIES
NUMBER OF
DWELLING
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TYPE OF CONSTRUCTION
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CODE
OCCUPANT
GROUP
DASCRIBE WORK TO BE DONE
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Description FEE Description FEE
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Plan Check State Surcharge
HEAT SOURCE LOT SLOPEO,6 ST9D 6AT
Building Permit City Surcharge
PLAN CHECK NO: &i
Plumbing &e) Base Fee
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Mechanical
2 DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
t: SEPARATE PERMISSION. Grading
cc PERMIT APPLICATION: SEE ECDC 19.00.605(A)(5)
Lu Engr. Review Recording Fee
PERMIT LIMIT: SEE ECDC 19.00.0050)(6)
SEE BACK 0 . F PINK PERMIT FOR MORE INFORMATION Engr. Inspection Plan Chk. Deposit
U) &APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
W IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review Receipt #
M 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 Fire Inspection Total Amt. Due
, 1
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.* Landscape Insp. Receipt A
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATI(;N APFYRO'VA'L
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF CALL This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRIJC_ 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 THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATI RANCE AND RCW 18:27. F!"51, §'IGNA)YRE DAII
.(425)
!SIGN&AUR WNER OR DATE S GNED 771-0220
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REL �D Y IPTE
JD EXT. 1333
ATTENTION ly
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 -INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER GOLD . ASSESSOR
6/05 1 PRESS HARD - YOU ARE MAKING 4 COPIES
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