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PERMIT
CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB SUITEAPT4
OWNE NAME/NAME OF BUSINES
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PLAT NAME'SUBDIVISION NO. LU NO. LID NO.
MAILING ADDRESS LID FEE S
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/ Rw PormA Requ�rod ❑
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CITY �/� ,,/f (` ry,�Z`/IP TELEPH NEy� !l, EXISTING _ _ _. -. __.._ PROPOSED -_. ,. _ _ .-_ _ _._. Inspection Roqu red ❑
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NAME METER SIZE LINE SIZE N0. OF FIXTURES PRV REQUIRED
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STATE LICENSE NUMBER EXP TION DATE CHECKED BY FIRE REVIEWED BY DATE ¢
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❑ NEW RESIDENTIAL ❑ PLUMBING / MECH ❑ WAIVER - ALLOWED PROPOSED - ALLOWED PROPOSED
❑ C MMERCIAL COMPLIANCE OR D STUDY j
❑ ADDITION ❑ CHANGE OF USE LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
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❑ REMODEL MULTIFAMILY ❑ SIGN z M
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❑ REPAIR ❑ CYDS ❑ ( X FT.) PARKING LOTAREA PLANNING REVIEWED BY DATE a C
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GARAGE RETAINING WALL FIRE SPRINKL REMARKS ! 10 Z
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Description FEE Description FEE D
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HEAT SOURCE LOTSLOPE VESTED DATE Plan Check State Surcharge t =
PLAN CHECK NO Building Permit City Surcharge
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Plumbing Base Fee 0
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical n
t BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC 171
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION, Grading
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
W PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Review Recording Fee
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection Plan Chk, Deposit
N •APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF Fire Review Receipt #
EDMONDS, WASHINGTON, ITS OFFICIALS; EMPLOYEES, AND AGENTS FROM ANY AND
a ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY Fife Inspection TO
Amt. Due
= FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
O 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.• Landscape Insp. 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 CALL This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC• Buil Odicial or h srhbr Deputy' and Fees are paid. and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION ace pt FOR acknowledged In space provided
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO z fir
WORKMEN'S CO SATIONINSURANCEANDRCW19:27. /AnC\ FI StYJATU E DATE
SIGNAT OWNEF( ): DATE SIG �� 771 -0262G0
O2DD 1 i .
BELE SED BY DATE
ATTENTION
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
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