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PERMIT EXPIRES
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DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS
SEPARATE PEA�tMAROUEES, ETC.) WILL. REOUIRE
ssIoN.
STATE SURCHARGE
2 D DAYS
PERMIT APPUCATION 18
PERMIT LIMIM. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG REVIEWFEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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�APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESOPS
IN INTEREST, AGREES TO DEFEND AND HOLD HARMLESS THE CITY OF
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FROM TH To ISSU 'FY EGA EDUCE A E OUIREMENT OF ANY CITY ORDINANCE
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TOTAL AMOUNT DUE
READ THIS APPLICATION. THAT THE INFORMATION
IHERE Y ACKNOWLEDGE THAT I HAVE
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WNER R THE OULY AUTHORIZED AGENT 01
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IN VIOLATION OF THE LAS i F THE STATE OF
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WORKMENS COMPEN�ATJON I=NCE AN.ACW IS �l
FICI LS SIGNATURE DATE
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771-022Q-
RE AS D BY D TE
J�CT 3�3
ATTENTION
711-0221
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI�
ORIGINAL - FILE - YELLOW � INSPECTOR
- ASSESSOR
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DATE
og PERMIT EXPIRES
PERMIT
CITY OF EDMONDS NUMBER
JOB
CONSTRUCTION PERMIT APPLICATION ADDA
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OWNER NAMENAME F BUSINESS PILAT NAMSISUBDIVISION NO. I LOT NO, I LI NO.
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NAME YES 0 No
REMARKS
ADDRESS —1—TRAI—P RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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FIRE REVIEWED By
DATE
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REMARKS
PRnr.RFSS INSPECTIONS PER UBC 1081FINAL
INSPECTION REO
VALUATION I FEE
PLAN CHECK FEE
0
qcE GLAZING 'I*
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BUILDING
PLAN CHECK NO:
VESTED DATE
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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
GRADiNGIFtLL
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
...... . ... . ......
SEPARATE PERMISSION,
STATE SURCHARGE
MIT APPLICATION; 180 DAYS
PER'
PER
PERMIT UNIT,. I YEAR - PROVIDED WORK IS STARTED WITHIN 18D DAYS
P ' BAD"
Y:
ENG. REVIEW FEES
SEE BACK OF P114K PERMIT FDA MORE INFORMATION
A C K
ON BEHALF OF HIS on HER SPOUSE, HEIRS� ASSIGNS AND SUCCESORS
T SHALF."
"�WAY
;APPLICANT
INTEREST, AGREES TO:ND MNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
1 IN A.
S ' FEES T"
a ED ONDS, WASHINGTON. TS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANYAND
M S NOT"N. IT
Mo
LAND$CA IN
INSPECTION FES
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i FWHATEVER NATURE,ARISING D RECTLYORN—
ALLCLARAS FOR DAMAGESO
A
FR M THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
NGE OF T"
DEXED ANYCITYoRDWANCE
FYWAIVEO REDUCEANYREOU;REMENT OF
To Mo. I y , W
"MMol'o
PLAN CHECK DEPOSIT
T IN ANY W Y THE CITY $ ABILLITY TO ENFORCE ANYOR.INAN.E PROVISION.
N OR LIMITT
TOTAL AMOUNT DUE
REG.
I HEREBY ACKNOWLEDGE THAT: HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT. A 0 THAT AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
11 IPP$ic _ I, a p0mit ��bl by I
THE OWNER. IAGREENTO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
CALL
dl o' ojj�—] NVIo, DbPWY: .�d F .. P.0, -d
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TION: AND IN DOING T WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
HE
OF WASHINGTON RELATING TO
FOR INSPECTION
.,—, i � ... I—ld �� m p,ovid-
IN VIOLATION OF THE LABO CODE OF THE STATE
WORKMEN'S COMPENSATION fl�$ORANCE AND ACW 18.27.
—
QFFICI LS SIGN TURE DATE
I I
SIGNATURE (OW�R AGENT)
I DATE
7D x,,
(425),
771-92!0-�
A. AS 0 BY
A-FlENTIO
"T 3
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCT— T 71-0221
L
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CA%F�%�,o
ORIGINAL, PIL YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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