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CONSTRUCTION PERMIT APPLICATION R5 ao
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NUMBER NUMBER OF CRITICAL
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/ NUMBER
DESCRIBE WORK TO BE DONE IATTACH PLOT PLAN).
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SUBDIVISION NO .
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING_______ REOUIREDDEDICAIION ._... _._... _.
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ALLOWED
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CHECKED BY TYPE OF CONSTRUCTION CODE
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OCCUPANT
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SPECIAL INSPECTOR
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OCCUPANT
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MARKS
PROGRESS INSPECTIONS PER UBC 305
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FINAL INSPECTION REQUIRED
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VALUATION
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Plan Check No. ( - - /'
MECHANICAL
This Permit covers work to be done On private property ONLY.
GRADINGPILL
Any construction on the public domain (curbs, sidewalks,
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driveways, marquees, etc.I will require separate permission.
STATE SURCHARGE
SV
Permit Application: 180 Days
STORM DRAINAGE FEE
Permit Limit: 1 Year -Provided Work Is Started Within 180 Days
"Applicant. on behalf of his or her spouse, heirs, assigns and
ENG. INSPECTION FEE
,r successors in Interest. agrees to indemnify, defend and hold
w harmless the Clty of Edmonds, Washington, its officials,
f employees, and agents Irom any and all claims for damages GI
IF Whatever nature• arising directly or indirectly from the issuance
t Of this permit. Issuance Of This permit shall not be deemed to
PLAN CHECK DEPOSIT
;
omotlify. waive or reduce any requirement of any city ordinance
the City's to enforce any ordinance
pq
r no Ilmd in any way ability
provision."
TOTAL AMOUNT DUE
�SU
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I hereby acknowledge that I have read this application; that the
ATTENTION
APPLICATION APPROVAL
Information given is correct; and that I am the owner, or the duly
authorized agent of the owner. I agree to comply with city and
THIS PERMIT
This application
is not a permit
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state laws regulating construction: and in doing the work authoriz•
ed thereby, no person will be employed In violation of the Labor
AUTHORIZES
ONLY THE
signed by the Building
his/her
Official or his/her
Code or the State of Washington relating to Workmen's Compensa
WORK NOTED
Deputy: and fees
are paid, and receipt is
lion.Insurance and RCW 18.27.
INSPECTION
acknowledged in space provided.
IO NATURE ,OI•:NEP OR AGENTI
1
nAIE SIGNED
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DEPARTMENT
CITY OF
0 F LS NATURE
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EDM0 4
✓ V�/��
CALL FOR
RELEASED B
DATE
ATTENTION
INSPECTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
77 i Y —0220
ORIGINAL — F,le
YELLOW — Inspector
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A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. UBC
CHAPTER 3.
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PINK — Oarer
GOLD — Assessor �'
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