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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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CITY
NAME
PERMIT EXPIRES
US PERMIT
ZOENE NUMBER
JOB ... -m RP SUITE/APT#
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PI -AT NAMEISUBGtVISION NO. LOTNO, LID NO.
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NAME
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CITY
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CHANGE OF USE
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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 MAR USES, ETC.) WILL REQUIRE
SEPARATE PERWisslooN.
STATE SURCHARGE
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 18B DAYS
ENG. REVIEW EES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON BEHALF OF HIS DR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
FLYH.Y "'ITY'S
'API
;APPLICANT�
INT REST, AGREES TO INDEMNIFY. DEFEND AND NO LD HARMLESS THE CITY OF
N E ANY AND
LANDSC01PI
OMONDS, WASHINGTON. ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM
S ED B TOY
� F ALL CLAdMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLYOR INDIRECTLY
$ E AGES
INSPECTION FEE
RECEIPT
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c FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
DEXED TO MODIFY. WAVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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WITINAN TO ENFORCE ANY ORDINANCE PROVISION.�
No , IT Y WA T.EEG ABILITY
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TOTAL AMOUNT DUE
R ECE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT. AND THAT I AM THE OWNER, on THE DULY AUTHORIZED AGENT OF
Thl Ipplill— �' "I - P—It
THE OWNER, I AGREE To COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
CALL
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TION. AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
WASHINGTON RELATING TO
FOR INSPECTION
dOPUIYi
IN VIOLATION OF THE LABOR CODE OF THE STATE OF
WORKMEN S COMPENSATION INSURANCE AND RCW 113.21
NERIRAG T)
ATE $1 NED
ID
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771-0220
ATTENTION
EXT 333
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 - YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109
FAX
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION.ON TH PUS LIC
DOMAIN ICURBS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC I, WILLEREQUIRE
SEPARATE PERMISSION.
GRADINGIFILL
STATE SURCHARGE
PERMIT APPLICATION: DAYS \N
K IS STARTS. W
._,",PERMIT LIMIT', I YEAR PROVIDED WOR IIHIN 18�64\
SEE BACK OF P1 NK PERMIT 'OR MORE INFORMATION t. "
ENO REVIEW FEES
I
re -APPL'�ANT,ON BEHALF OF S AND 9ftCESORS
C IS OR HER SPOUSE, HEIRS, ASSIGN
IN IN4REST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMILt—
2 EDMONDS,WASHiNGTON. ITS OFFICIALS. EMPLOYEES. AND AGENTS FROMI INV 11
LANDSCAPING
INSPECTION FEE
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,, ALLCMMS FOR DAMAGESOF WHATEVER NATURE AAtSlNGDl KIRE
NOT BE
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x FROM THE ISSUANCE OF THIS PERMIT SSUAN�E OF THIS PERMIT SiVLC
F
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REOUIREMENT 0 ANY CITY ORDINANCE
PLAN CHECK DEPOSIT
NOR LIMIT IN ANY WAYTHE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION,'
_
To
I HEREDY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION; THAT THE INF RMATION
GIVEN IS CORRECT, AND THAT AM THE OWNER OR THE DU� AUTHORIZED AGENT OF
�
THE OWNER. I AG91E TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
WASHINGTON RELATINGTO
FOR INSPECTIIO�
IN VIOLATION OF THE LAOO�C.�� OF THE STATE OF .
WORKMEN'S PENSATION INSURANCE AND RCW 18,27,
COM
eDWNEF� .� AG )�
I DATEV NED
(425)
(.UE
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sl 16121
771-0220
ATTENTION
EXT 333
IT IS UNLAWFULTO USE OR 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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FBI—, � --d I A DATE
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