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EXPIRES
CITY OF EDMONDS
USE PERMIT
ZONE NUMBER
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CONSTRUCTION PERMIT APPLICATION
JOB
ADDRESS All- -
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OWNER NAMEMAME OF BUSINESS
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PLAT NAMEJSUBDIVISION NO.
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REMARKS
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STATE SURCHARGE
2 PE MIT APPLICATION: 11113 DAYS
.1 PERMIT LIMIT, I YEAR" PROVIDED WORK 'SSTARTEDWITHIN l6DDAYS
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SEE BACK OF PINK PERMIT FOR MORE INFORMATION
LICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCFSORS
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;AP
N INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
AND
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2 ED HINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY
- MoNDS'WAS CTLY
ALLC�;MS FOR DAMAGESOF WHATEVER NATURE� ARISING DIRECTLYOR NWRE
INSPECTION FEE
RECEII T
FROM THE ISSUANCE OF THIS PERMIT� ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITY S ABILITY TO ENFORCE ANY ORDINANCE PRCWISRDN,�
TOTAL AMOUNT DUE
R CEIPT
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION, THAT THE INFORMATION
APPLICATION APPROVAL
I HEREBY
GIVEN IS CORRECT, A D THAT I AM THE WNER� OR THE DULY AUTHORIZED AGENT OF
T'hlPPIlc I— P.1 IIII ll,ld by th,
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
THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
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IN VIOLATION OF THE LABOR CODE OF
WORKMEN'S COMPENSATION INSURANCE AND HOW IB.27
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771-0220
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IT I S UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE YELLOW -INSPECTOR
A
BEEN GRANTED. LED SECTION 109
FAX
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REQUIRED SETBAC (�T
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0 ADDITION
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CO PLIANCEOR
CHAKGE OF USE
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DESCRIBE WORK TO BE GONE
REMARKS
OGRESS INSPECTIONS PER UBC I UUMMIN-1 INSPECTION REO
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iFEE
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HEAT SOURCE
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I_ BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PU BLIC
5 SIDEWALKS, DRIVEWAYS, MAROUEES, ETC.) WILL REQUIRE
GRADINGIFILL
DOMAIN ICUREIS.
m SEPARATE PERMISSION.
I-
STATE SURCHARGE
PERMIT APPLICATION 180DAYS
I YEAR - PROVIDED WORKIS STARTED WITHIN 1800 S
ENG. RAVIEW F ES
PE MIT LIMIT:
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a POF0 JOGE INFORMATION
SEE�BACK OF PINK PERM I
OF H,EGR M. SPOUS�� HEIRS. ASSIGNS AND SUCCESORS
THE CITY OF
;Ap',,EC�AEN�T�.Oa,.GEMAL,
NT R E. To 'ND0EMNIC'y CIIND AYNEII��IIIOLNIIDMAF.LFSS
S' EMPLO A AGENTS FROM ANY AND
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LANDSCAPING
INSPECTION FEE
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LLCLA' SB'F.B . E F WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
A . A.A.
RECEIPT
MIS M BE
FROM THE ISSUANCE OF T PERMIT. ISSUANCE OF THIS PERMIT S ALL NOT
CITY ORDINANCE
PLAN CHECK DEPOSIT
DEEMED FY, WAN REDUCE ANY REQUIREMENT OF ANY
To Mo.' SOR E PROVISION.'
To I'D To ENFORCE ANY 0110INANO
RECEIPT
NOR LIMIT IN ANY WAY THE TY'SASILITY
TOTAL AMOUNT DUE
ADTH, THAT THE %FORMATION
I HEREBY ACKNOWLEDGE THAT I HAVE RE I S App,.C�ATI�ON
APPLICATI N OVAL
. AUTHOR'. AGENT OF
GI EN IS CORRECT . AND THAT I AM THECOWNEF6 �
Th" 'pp�"all I, cat I poeall U-61 sigc.V by -
I HS OWNE . I AGREE To COMPLY WITH ITY AN STATE LAWS REGULATING CONSTRUC-
BE EMPLOYED
CALL
wtag , 1,1111,01 Cape y: ad Fall am P V, and
Bu, I
TiON; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL
OF WASHINGTON RELATING TO
FOR INsPECTION
ipt I, nkao—dgld 11 pace, pcovided.
IN VIOLATION OF THE LABOR CODE 0 THE STATE
Won C P5NSATION INSURANCE AND RCW 18,27,
KMEN'S OM
0 L, At I
?NATU
SIGNATU
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s' 'GNE
ATE s
(425)
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771 0220
ex 1 ;3;3;3
EASED BY OAT
ATTENTION
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
/ORIGINAL
FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI�
FILE YELLOW - INSPECTOR
GOLD - ASSESSOR
A
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - OWNER
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