20000365.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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NUMBER
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PUBLIC RIGHT OF WAY PER 0111CIAL STREET MAP 1*
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REMARKS
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REMARKS
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
B D ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
GRADINGWILL
DEMONE(CURBS, SIDEWALKS, DRIVEWAYS, MAROUEES, ETC.) WILL REOUIRE
0 AtN
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SEPARATE PERMISSION.
2 PERMIT APPLICATION: IBQ DAY.
PERMIT LIMIM I YEAR ' PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
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SEE BACK OF PINK PERMIT FOR ORE INFORMATION
'APPLICANT. ON BEHALF OF HIS 013 HER SpoUSE� HEIRS, ASSIGNS AND SUCCESORS
CITY OF
ENG. INSPECTION FEE
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IN INTElIESt=.lTSC`.O o 'END `y`EFH-`I,%=T ANYAND
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DAMAGES '
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A LCLAIMSFoR
L M e LANGE F H PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
PRO TH ISS o T 15
PLAN CHECK DEPOSIT
CEANY ED OF ANY CITY ORDINANCE
oGIrY , UIREMENT
EMEDT AWAIV OR REDU
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NOR LIMIT INANY W Y THE CITY ABI YTOE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION. THAT THE INFORMATION
DUL AUTHORIZED AGENT OF
LY
GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR THE
ITY A STAT LAW RE-ULA G CONSTRUC-
To CoM P L'UTHTH
CALL
THE OWNER
RCI Z TI`.�'..yEN. PE�RSICN WILINSE EMPLOYED
TIO.; AND IN, HE WORK A ED A
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FOR INSPECTION
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON
WORKMEN'S COMPENSATION INSURANCE AND RCW 16.27,
17IGHED
(425)
SIGNATURE (OWNER OR AGE�
771-0220
EXT 333
ATTENTION
IT IS UNLAWFUL TO USE 08 OCCUPY A BUILDING 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
FAX
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FINAL APPROVAL FOR
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'DATE RECEIVED
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PERMIT
7,
CITY OF EDMONDS j NUMBER
JOB 4�, _I�
BE' SURTEIAPTN
CONSTRIUCTION PERMIT APPLICATION ADD SS
IN I I
OWNER NAMENAME OF BUSINESS
PLAT I spivisio 0 LOT NO. LID NO.
LID FEE
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NAME YES 0 No 0 g
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR SION CONTROUDRAINA,
(ADDRESS
CITY lip TELEPHONE
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ENGINEEnIN
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CITY ZIP TELEPHONE
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THIS PERMIT AUTHORIZES =E WOLAYK NNY CONSTRUCTION ON THE PUBLIC
BE .. E ON P`"VAi YON . A GRADING/FILL
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DOMAIN .U..S. .1..WAIKS, ..IVEW... IMA ... EE., T..) WILL B.0 RE
SEPARATE PERMISSION,
L SURCHARGE
PERMIT APPLICATIONt 180 DAYS
PERMIT LIMIT. I AR, PROVIDED WORK IS STARTED WITHIN 180 DAYS ENO. REVIEW FEES
YE
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
END. INSPECTION FEE
PLICANT, ON BEHALF 0 F HIS OR HER "'USE " 'L,S1.11B AND SH.CES.11S
NP INTEIIIIT.=.ETI.TO EMNI , DEFEND �NC`N. . HARMLESS THE CITY OF LANDSCAP NO
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EMPLOYEES, AND AGENTS FROM ANY AND INSPECTION FEE
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LCLAIMIFOIDIMAGIS-F WHATEVER NATURE' AR'S'NO DIRECTLY A ND'qPGTl
EPOSIT
ROM THE E OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE PLAN CHECK DEPOSIT
.SUANO
AN REQU$REMENTOFANYCITYORDINANC
D EMED TO MODIFY, WAIVE OR REDUCE Yo
NOR LIMIT IN ANY 'NAY THE CITY'S ABIUTY T ENFORCE ANY ORDINANCE PROVISION!� RECEIPT
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE TH HAVTEHREOAD THIS APPTtCATlUN; THAT THE INFORMATION APPLICATION A ROVAL
OF
TI, '1 .1— m ,.t . ..... tt I b, ft
GIVEN IS CORRECT, AND THAT: AM E WNE On , 0 LY AUTHORIZED AGENT
THE OWNER. I AGREE TO C AT LY WITH CITY AND ATING CONSTRUC. CALL Bu"III -1h., D.Puty, F— 110 ptt,tt .�d
0 STATE LAWS REGUL D
TION; AND IN DOING THE WOAKP AUTHORIZED T ERESY No PERSON WILL BE EM LOVE plit.,k-11,19 —ded.
STATE OF WASHINGTON RELATING To FOR INSPECTION
IN VIOLATION OF THE LABOR CODE OF THE
WORKMEN'S COMPENSATION INSURANCE AND ROW �S 27, OFF AL IGNATUR
SIGNATURE IOWNER A AGENT) E SIGNED (425)
5 ED By
EXT 333
ATTENTION
OR STRUCTURE UNTIL
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING 771-0221
INS ECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI� ORIGINAL - FILE YELLOW - INSPECTOR
P ASSESSOR
A FINAL PINK - OWNER GOLD -
OF OCCUPANCY HAS BEEN GRANTED, LIBC SECTION 109 FAX
CATE