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CONSTRUCTION PERMIT APPLICATION
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. AN' CONSTRUCTIoCN ON THE PUBLIC
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DDMAIN (CURBS, SIDEWALKS. DRIVEWAYS MARQUEESIET )WILLR,QUIRE
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IT APPLICATION: 180-AYS
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WHATEVER URE. ARI5lNGDlRECTl_YOR INDIRECTLY
RECEIPT
ALLCLAIMS FOR DAMAGES OF IN
x FROM THE ISSUANCE OF THIS PERMIT SSVANCE OF THIS P ERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
A IREMENTOF ANY CITY ORDINANCE
DEEMED To MODIFY, WAIVE OR REDUCE NYR QU
ANY ORDINANCE PROVISION.'
RECEIPT
0 NORLIMIT IN ANYWAYTHE CITY SABILITY TO ENFORCE
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION, THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER. THE DULY AUTHORIZED AGENT OF
OR
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THEOWNER I AGREE TOCOM—W17H CITY AND LAWS REGULATING CONSTRUC
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RELATING TO
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FOR INSPECTION
IN VIOLATI ON OF THE LABOR CODE OF THE STATE OF WASHINGTON
WORKMEN S COMPENSATION INSURANCE AND RCW 18.27
rFICIALS SIGNAT DATE
1 D E 21IG" D
(425)
771-0220
BAT
EXT 3J;3
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPRCVAL OR A CERTIFI-
ORIOINAL-FiLE - YELLOW INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. USC SECTION 109
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VM DEPARTMENT DATE
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REMARKS
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ON THE PUBLIC
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13 EWALKS. DRIVE 'S, MARQUEES. ETC.) WILL REQUIRE
DOMAIN ICURBS,110
GRADINGIFILL
SEPARATEWPEARMISSION.
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STATE SURCHARGE
PIRMITAPPLICATIOW "'DAYS
PERMIT LIMIT. I YEAR - PROVIDE. WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
OF HIS OR HER SPOUSE. HEIRS. ASSIGNSAND SUCCESORS
,APPLICANT. ON BEHALF HARMLESS THE CITY OF
`TY OF
`TY OF
`TY OF
INTEREST. AGREES TO D OF
L N S PI G
�NDEMNIFYLDEFEEMNPDLOAYNEDESH,OALND AGENTS FROM A`NTyyAND
M EDMONDS. WASHINGTON, TSOFFiCI E.
INSPE TION FEE
ALLCLAINIS FOR DAMAGESOFWHATEVER NATUR ARISING DIRECTLY OR INDIRECTLY
OF THIS ERMITIT�HALLDNOTNCE
RECEIPT
PLAN CHECK DEPOSIT
x FROM THE ISSUANCE OF THIS PERMIT ISSUANCE
TO MODIFY. WAIVE OR REDUCE ANY PEOUIREMENTOF ANY 0 (OR INA E
T=
DEEMED
NFO
NOR LIMIT IN ANYWAY THE CITY'S ABILITY TOE ACE ANY ORDINAN�,E PROVISION.-
RECEIPT
TOTAL AMOUNT DUE
I HE REBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION. THAT THE IN FORMATION
APPLICATION APPROVAL
GIVEN RRECT, AND THAT I AM THE OWNER, 08 TEE DU'LIRAUTHORIZIED AGETT OF
IS CO CONS uc�
T I'll I "I "I,:
THEOWNER I AGREE TO COMPLY WITH CITY AND STAT LAW EGULAT,
ILL ` D
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CALL Sulloll,, Doll
0 THEREBY. N OPEASON
TION; AND IN DOING THE WORK AUTHORIZE RELATILOY
OF WASHINGTON 11; TO
i., ol-Kda d,� I—. P-lo.d.
FOR INSPECTION
IN VIOLATION OF THE LAID" CODE 01 THE STATE
WORKMEN S COMPENSATION INSURANCE AND PCW 10.27. -
-
FICIALS SIGNATURE, DATE
(425) 1 ,
11 �)
771-0220 LEASED By DAT
EXT 333
ATTENTION
T IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
FINAL NSPECTION HAS BEEN MADE AND AP ROVAL OR A CERTIFI-
I P
ORIGINAL FILE - YELLOW - INSPECTOR
A
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK - OWNER - GOLD - ASSESSOR
FAX