20000351.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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REMARKS
PROGRESS INSPECTIONS PER UBC 1081FINAL INSPECTION REQ'D
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VALUATION
FEE
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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
GRADINGIFILL
2 ETC.) WILL REQUIRE
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES.
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d SEPARATE PERMISSION.
STATE SURCHARGE
PERMIT APPLICATION: 100 DAYS
T PERMIT LIMIT. I YEAR � PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG, REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON SEPAL OF HI S OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
OF
I
;APPLICANT,
INTEREST, AGREES TO INDEMNIF �LDEEND AYN�%H.OLNID=11151 THE CITY
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ALLCLAIMSFOR AMAGESOF WHATEVER NATURE,
D ARI BE
RECEIPT
F ROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL HOT
PLA14 CHECK DEPOSIT
V REQUIREMENTOF ANY CITY ORDINANC
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ANY ORDINANCE PRO11SION.
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN I CORRECT. AND THATAM THE OWNER. H DULY AUTHORIZED AGENT OF
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CITY AND SOTATT C.NS
THE OWNER i ACRIEE TO COMPLY WITH E REGULATING THUD
EMPLOYED
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IN LAT ON I THE LABOR CODE OF THE 5
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WORKMEN'S COMPENSATION INNa�WE AND ROW 18.27.
DATE
FFICIAIS SIEINATU�k
EITI DATESIGNED
(425)
OATM
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771-0220
R LEASED BY
EXT 333
ATTENTION
IT IS UNLAWFULTO USE 01, OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE - YELLOW - INSPECTOR
ASSESSOR
A
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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CONSTRUCTION PERMIT APPLICATION JOB SUITEIAPT#
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A � THSP
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ATYoN C NsTRUCTIO ON HER
GRADINGIFILL
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SEPARATE PERMISSION.
STATE SURCHARGE
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REVIEW I'll
PERMIT LIMIT: I YEAR, p R Ge,, j TNI. UIB DAYS
SEE BACK OF PINK P ,TF R RMATION
,Ap,LK,AoT,=lT.ol 11111 HER rp.US�, EIRS, ASSIGNS AND SUCrESORS
FEND AND HOLD APMLESl THE CITY 01
LANDSCA ING
NTERES INGE
IN EMN"Y EMLoYE�S�AND
ASHINGTON�ITS OFTIC12SE A ENTS FROM ANY AND
INSPECTION FEE
RECEIPT
ED ONDS' I DAMAGE RE. ARISING DIRECTLY OR INDIRECTLY
ALLC I SFO OF HATEVER NATO BE
i
FRO HE ISSUANC OF THIS PER IT. ISSUANCE OF THIS PERMIT $HALL NOT
0 E MODI Y� NE RPEDUCE REQUIREMENTOF A14YCITY ORDINANCE
ANY ORDINANCE PROVISION.*
PLAN CHECK DEPOSIT
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I N A T NANY THE C TY'S ABILITANTY0 ENFORCE
Ll IT,
TOTAL AMOUNT DUE
:S wu
10&L�
N., THAT THE INFORMATION
HAVE READ THIS APPLICATIOLY
APPLICATION AP
r,,
P
,ggESY TEAN�E ;HATT: AM THE OWNER, OR THE DU ALT ORIZED AGENT OF
I IV S=L I TRUC-
STATE LAWS REGULATING CONS
CALL
Theloplimati.ei.e.I.Penealti
hNA,Qr Dad dy: ad Fees", P.1d. and
THE OWNER. I AGREE TO COMPLY WITH CITY AND
TION;ANDINOOIN THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
RELATING TO
GTHE
FOR INSPECTION
Balt ding 011ical ,
oCoipii,,,k,mlodoodi,,p,,Optmldod.
IN VIOLATION OF LABOR CODE OF THE STATEOF WASHINGTON
W
AND PC 1
FICIALS SIGN ATU DATE
WORKMEN'S COMP .27-
ENSATIONI��E
TGNAikins mww�l �T)
E SIGNED
(425)
771,0220
R LEASED BY D
EXT 333
ATTENTION
UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
W INSPECT A
IT IS
I NSPECTION HAS BEEN MADE AND APPROVAL OR A CEPITIFI�
ORIGINAL -FILE - YELL
OWNER - GOL -ASSESSOR
A FINAL
OF OCCUPANCY HAS BEEN G'�ANTED. UBC SECTION 109
FAX
PINK -
CATE