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SIDE SEWER PERMIT
PERMIT NO: 9531
PERMIT EXPI RES S //a /Q
Address of Construction: 1 8 z 12 '1 uJ 4 v L_: d ud-T \A/4 LID# aiS
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Property Tax Account Parcel No.
Attach copies of all access and utility easements Verified and Approved b
Owner and/or Contractor: (I a i?)& C. ea,qo4 J'sA: 4,),-�- " L,:)/ e
Contractor License #: Building Permit #:
Single Family
Fj Multi -Family (No. of Units
F] Commercial (No. of Units
R Public'
Inva.sion into City *Right -of Way: El Yps N No
*RW Construction Permit
Cross other "Private Property: Yes No
"Attach legal description and copy of recorded easement.
Owner,or contractor signature and acknowledgement statement:
By signing for this permit I certify that I have read the City's public handout entitled
Side Sewer Specifications, and shall comply with all City requirements outlined therein.
WM
0
Date
02 CALL DIAL-�A-DIG (1-800-42A 5555) BEFORE ANY EXCAVATION 9
FOR INSPECTION CALL 425-771-0220 extens'ionf:_3_�=
HOUR NOTICE REOUTRED FOR ALL INSPECTION REQUESTS
Partial Inspection: Date: Initial:
Partial Inspection: Date: Initial:
FINAL INSPECTION APPROVED: Date: Initial: As -built to Street File:
t- PERMIT MUST BE POSTED-ON2JOB SITE t-
White Copy: File dreen Copy: Inspector ' Buff Copy: Applicant
L;temp;bldg;forms;sspermitjlg4/00 .
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EXEMPTION FROM CONTRACTOR REGISTRATION
VERIFICATION FORM
The undersigned property owner or contractor has applied for a building permit from the City of
Edmonds and claims that he/she/it are exempt from providing contractor registration in accordance with
the provisions of RCW 18.27. The property owner, by their signature below hereby verifies to the City of
Edmonds that:
0 Value of work under $500.00. The aggregate contract price of labor and materials
and all other items required for the project is less than $500.00 and is not part of a larger
opertation to be undertaken on the property. The person employed to do this work has not
advertised nor otherwise put himself forward to the permittee to be a contractor or
qualified to engage in the business of a contract. RCW 18.27.090(9).
Work performed personally on own property., The undersigned verifies that all work
done under this permit will be done by the permittee personally on his/her own property
and that the improvements constructed on the property are hot being undertaken with the
intention and purpose of selling the improved property.
0 Commercial property exemption. The permittee is the owner of commercial property
and the owner's own employees will perform all maintenance, repair and alteration work
on the property. No work will be done by contract under the permit. RCW 18.27.090(13).
0 Licensed architect, engineer, electrician or plumber. All work performed under this
permit will be perfon-ned by an architect, civil or professional engineer, licensed electrician
or licensed plumber operating within the scope of his or her license. RCW 18.27.0 . 90(14).
0 General Contractor. The owner is the General Contractor for the project and -is required
to hire a minimum of two licensed subcontractors (unrelated building trades or crafts). The
general contractor is responsible to verify all State licenses of subcontractor. RCW
18.27.010
THE UNDERSIGNED PROPERTY OWNER HEREBY VERIFIES THAT ALL
INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST'OF HIS
OR HER KNOWLEDGE AND ACKNOWLEDGES THAT IF ANY OF THE INFORMATION
PROVIDED ON THIS FORM IS FALSE, HE OR SHE UNDERSTANDS THAT THE BUILDING
PERMIT WILL BE IMMEDIATELY REVOKED AND ALL FEES PAID FORFEITED.
Dated this dayof Qu1L#4-r -, 20 d? I
PROPERTY OWNER/PERMITTEE
WITNESS:
M N An oo
AIO, "M
LATEMP\BU1LDfNG\F0RMS\exernp contractor regis verif forTn.doc03/28/01
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CITY [IF'
EDMONDS
SIDE SEWER AS -BUILT
ADDRESS
18212 72ND AVE W.
PERMIT
NUMBER 9531
HOMEOWNER CHARLES
ROACH
CONTRACTOR HOMEOWNER
DATE
xxxxxxx
DRAWN
BY
ISMAEL ABILA
------------ I - - - — - -
(j)
ACCURACY The information shown oil the
CL .
N-1IViW fO,'u-oe by the City of Edm Ofids, its employees
Tho City of Edirnonds does not warrant the accuracy of
set tort.) on the map. AnY Person or entity C--y
S! C"d �ondue, an IngI.177, rev,,
the map, includin :A
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