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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER 11"11A"E 11 IINESS
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PERMIT EXPIRES 14�/W
USE PERMIT '701S27
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BEGONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN ICURDS, SIDEWALKS, DRIVEWAYS' MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION,
PERMIT APPLICATION: 180DAYS
PERMIT LIMIT. I YEAR ' PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
;APPLICANT. ON BEHALF OF 81S OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
N INTEREST, AGREES TO :NDENINIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, TS OFFICIALS. EMPLOYEES, AND AGENTS FROM -1 AND
ALL CLAIMS FOR DAMAGES OFWHATEVEA NATURE. ARISING OIRECTLYORINDIRECILY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORMNANII, --b-
IHEREB ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
GIVEN IS CORRECT. AND THAT I A. THE OWNER. OR THE DULY AUTHORIZED AGENT OF
SPE IAL INSPECTOR JAREA I OCCUPANT
LIFED c] YES LOAD
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IN VIOLATION OF THE LABOR CODE 01 THE STATE Or WASHINGTON RE LATING TO FOR INSPECTIl
WORKMEWSCOMPEPSATION INSURANCE A)6RCW IB.27.
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771-0220
TTTENTION_ EXT1333
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-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX
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t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADINGIFILL
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SEPARATE PERMISSION.
URCHARGE
P -M ;T APPLICATION: 18D DAYS
PERMIT LIMIT'. I YEA' - PROVIDED WORK IS STARTED WITHIN i.0 DAYS
ING. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORM ION
A PPLIQANT. ON BEHAL OF HIS OR HER SPOUSE. HEIRS. AS.' GNS AND SUCCESORS
ENG. INSPECTION FEE
IN INTEFIEST� AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
AND
LANDSCAPING
EDMONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY
ALLCLAIMS FOR DAMAGES OF WHATEVER NATURE.ARISING DIRECTLI 114U....
INSPECTION FEE
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PLAN CHECK DEPOSIT
F CITY
DEEMED TO MODIFY. WAIVE 0 R REDUCE ANY REQUIREMENT 0 ANY ORDINANC
PROVISIOW
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0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE
TOTAL AMOUNT DUE
(p I � .
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
PPLICATION APPROVAL
GIVEN I S CORRECT, AND THAT t AM THE OWNER. OR THE DULY AU HOAIZED AGENT OF
ap 'P`
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 2MPLOYE D
WASHINGTON RE LAT ING TO
FOR INSPECTION
6PI
CODE OF T
IN VIOLATION OF THE LABOR STATE OF
WORKMEN S COMPFSATION INSURANCE ApRCW 18.21.
F ICI T
DAIE St
(425)
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771-0220
L5AS D BY DATE
EXT1333
44-TENTION_
i 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
P/If-
ORIGINAL FILE YELLOW -INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER GOLD -ASSESSOR
FAX JP-7-00
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