20000376.pdfCITY OF EDMONDS �
CONSTRUCTION PERMIT APPLICATION
MAILING ADDA SS
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NAME
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ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATIONDATE CHECKEDBY_
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E
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SEPARATE PERMISSION,
STATE SURCHARG
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PERMIT APPLICATION: 100 DAYS
"THIN "KI DAY.
PERMIT LIMIT, I YEAR ' PROVIDED WORK IS STARTED WITHIN 180 DAYS
VATI.N
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
N , INSPECTION �E
ENO. INSPECTION FEE
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'SIGNS AN" BUD FSoFG
'APPLICANT, ON BEHAL OF HIS OR HER SPOUSC HEIRS, ASSIGNS AND SUCCESORS
HARMLESS , E CITY OF
I
IN NTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
ANY AND
ANY
NO IS
LANDSCAPING
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AGENTS FROM
I EDMONDS, WASHINGTON, ITSOFFICIALS, EMPLOYEES. AND AGENTS FROM
AND
A CLAIMS FOR OAMAGESOFWHATEVER NATURE, ARISING DIRECTLYOR INDIRECTLY
INSPECTION FEE
INSPECTION FEE
RECEIPT
FLALOM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT $HALL NOT BE
PLAN CHECK DEPOSIT
PLAN CHECK ot S
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REOU113EMENTOF ANY CITY ORDINANCE
0 'OR LIMIT IN ANYWAY THE CITY'SA81LITY TO ENFORCE ANY ORDINANCE PROVISION.
TOTAL AMOUNT DUE
tHERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
IS
WITH CITY AND STATE LAWS REGULATING CONISTRUC*
CALL
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THE OWNEH� I AGREE TO COMPLY
DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
F"' dibg OluRal,X haffi,, Deputy:,. OessuIp"d."d
Sail uII
in
TION; AND IN
IN VIC I
LATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELAT NO TO
Is a space pnanudod�
FOR INSPECTION aipt 1, ckno,ledgad
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27,
OFFICIALS Tu
GNATUR DATE SIGNED
,
(425)
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771-0220
ELEA NY
ELIE BY
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ATTENTION
EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 10 1
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CEPITIFI-
ORIGINAL. FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109
FAX
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS,PERMIT COVERS WORK TO
I: HE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTR CTION ONTHEPUSUC
GRADING/FILL
2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS' MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
STATE SURCHAR
PERMIT APPLICATION: 100 DAYS
P. PERMIT LIMIt. I YEAR, PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FDA MORE INFORMATION
�APPUCANT. ON BEHALF OF HIS 08 HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
SNO INSPECTION FEE
IN INTEREST. AGREES TO INDEMNIFY� DEFEND AND HOLD HARMLESS THE CITY OF
ANY AND
I-AN'SCAP NO
' 2 ECI SHINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM
MONGS'WA
AULCI-AIMSFOR DAMAGESOF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
INSPECTION FEE
RECEIPT
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
CITYORDtNANCE
PLAN CHECK DEPOVT
D EMED TO MODIFY� WAIVE OR A50UCE ANY R50UIREMENTOF ANY
NE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
o OR LIMIT IN ANY WAY THE
TOTAL AMOUNT DUE
I HERE Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION A
DO RECT. A D TH I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
GIVEN' IS R
This Ippl,call.h Is 1-1 s I'll I
THE OWNER� I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
CALL
's
S. -B 1 111_1 - si., �d
TION. AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
OF WASHINGTON RELATING TO
INSPECTION
I'--V
IN VIOLATION OF THE LABOR CODE OF THE STATE
18,27.
WORKMENS COMPENSATION INSURANCE AND ROW
SIGNED
DATE�
(425)
OFFICIALS , §AN
SIGNATURE I T
't
771-0220
7ELEAS- BY
ATTENTION v
EXT 333
15
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
BEEN MADE AND APPROVAL 08 A CERTIFI-
ORIGINAL - FILE YELLOW - INSPECTOR
A FINAL INSPECTION HAS
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - OWNER GOLD - ASSESSOR