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PERMITEXPIRES
USE PERMIT
200,077
CITY OF EDMONDS
ZONE NUMBER
CONSTRUCTION PERMIT APPLICATION
JOB
ADDRESS
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PERMIT APPLICATI N: 180 DAYS
PERMIT LIMIT' I YEAR - RoVIDED WORK IS STARTED WITHIN 180 DAYS
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ENG. REVIEW PEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
-APPLICANT. ON BEHALF F HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
IN INTEREST. AGREES TO :NDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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OFANY 17YORDINANCE
ORDINANCE PROVISION,'
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
NT OF
8 THE DULY AUTHORIZED AGENT OF
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Y STATE LAWS FEGU STRU
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NO PERSON WILL BE EMPLOYEC�
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FOR INSPECT'll
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ATTEWTION
IT IS UNLAWFULTO USE OR OCCUPY ASUiLDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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FINAL APPROVAL FOR
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A', RECEIVED
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PERMIT EXPIRES
us PERMIT
ZONE 2040027
CITY OF EDMONDS
NUMBER
CONSTRUCTION PERMIT APPLICATION
JOB SUITEI�P!Tl
ADDRESS Q
OWNER NAMEINAME OF BUSINESS
JJ
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FLAT NAMEISUBDIVISION NO.
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPIERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
GMADINGIFILL
DOMAIN JCURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
n SIMIATE I
SURDIHARGE
C DAY.
PE MIT APPLICATION: 180
Ap
XTATE
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED W' H'N '00 DAYS
ENG. REVIEW FEES
SEE SACK OF PINK PERMIT FOR MORE INFORMfION
'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIG NS AND SUCCESORS
ENO. INSPECTION FEE
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLE SSTHECITY F
O'CA
L=
2 EDMONDS. WASHINGTON. ITS OFFICIALS. EMPLOYEES, AND AGENTS FRO. ANYAND
ALL CLAIMS FOR DAMAGES OFWHATEVER NATURE, ARISING DIRECTLY
_IN El
FROM THE ISSUANCE OF HIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCEANY R'OUIREMENT OF ANY CITY ORDINANCE
PLAN CHECK DEPOSIT
C NOR LIMIT INANYWAYTHECITY-SABILITYTO ENFORCE ANYORDINANCE PROVISION.-
CEIPT
TOTALA..UNl DUE
IR
IHEREB ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICAT
ON APPROVAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER ORTHEDULYAU6 TI ETTU01
TF 4C V
V
�TFU
THE OWNER, I AGREE TO COMPLY WITH CITY AN6 STATE LAWS AEG LICATZPCONS R C
CALL
T C 'LOY
ION;ANDIN DING THE WORK AUTHORIZED THEREBY. NO PERSON WILOSE EMPLOYED1
.d I ... ... -d-d
IN VIOLATION OF THE LABOR CODE 01 THE STATE OF VVASHINGT.NieRELAT�NG TO
FOR INSPECTION
a P P,
WORKMEN'S COMPENSATION INSURANCE AND RCW 16.21.
J425)
011 ICIA,LSSIGI URI DATE
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, -) , �,Ll � I-Iz-
SIGNATURE (OWNER ORAGE
FIQ_c,�
AT GNEO)
o
Ctl
0- -
17tid
771-0220
RIEIEA�EGS DATE
ATTENTION
EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION AAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE - YELLOW INSPECTOR
CATE OF OCCUPANCYIHAS BEEN GRANTED. UBC SECTION 109
FAX
PINK -OWNER - GOLD -ASSESSOR
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