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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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GRADING/FILL
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SEPARATE PERMISSION.
STATE SURCHARGE
PERM T APPLICATION: 100 DAYS
180 DAYS
03
PERMITLIMIT. I YEAR - PROVIOEDWORK ISSTARTED WITHIN
SEE BACK OF PINKPERMITFOR MOREINFORMATiON
ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
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;APPLICANT
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FROM ANYAND
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R DAMAGES OPWHATEVER NATURE, ARISING DIRECTLY OR INDIR CTLY
ALLCLAIMSFO E
THIS PERMIT SHALL NOT BE
INSPECTION FEE
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FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF
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0 NOR LIMIT IN ANY WAYTHE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISIOI'L
PLAN CHECK DEPOSIT
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RECEIPT
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TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THATI HAVE FEADT.IS APPLICATION: THATTHE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
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IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTIL 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE YELLOW - INS ECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK To
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC GRADING/FILL
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION. STATE SURCHARGE
YEPERIMITAPPUCATION! 180 DAYS
PERMIT LIMIT. I AR . PROVIDED WORK IS STARTED WITHIN 180 DAYS -emu
SEE SAC K OF PINK PERMIT FOR MORE NFORMATION
;APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGN ANDSUCCESORS
N NTEREST. AGREES TO INDEMNIFY' DEFEND AND HOLD HARMLESS THE CITY OF LANDSCAPING
'T'CN
E MONDE. WASHINGTON. ITS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANY AND INSPEC EE
ALL CLAIMS FOR DAMAGES OF WHATEV R NATURE, ARISING DIRECTLY OR INDIRECTLY
D E
F T
i: ROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE PIN CHECK DEPOSIT
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE
I NORLIMIT IN ANY PROVISION.'
TOTAL AMOUNT DUE
RECEIPT/
RECEIPT
2A 57.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATIGN� THAT THE INFORMATION
OR T E DULY A THORIZFD AGENT OF
GIVEN IS CORRECT, AND THAT I AM THE OWNER, HILAWSREU
H CITY AND E GULATiNGCONSTRUC
THEO NER, 1AGREETOCOMILYWIT STAT CALL
W LOYED
TION. AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPI
RELAT ING TO
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON FOR INSPECTION
WORKMEN., COMPENSATION INSURANCE AND RCW 18.21�
SIGNATURE (OWNER OR AGENTI DATE SIGN (425)
7 1— -- /- -�7 - -Z - 771-0220
APPLICATION APPROVAL
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EL E Y J E
EXT 333 'lit
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL FILE
PINK - OWNER GOLD - ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX