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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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STATE SURCHARGE
MIT APPLICATION: 1-P D
PER AVS
PERMIT LIMIT'. I YEAR - PROVIDED WORK IS STARTED WI HIN 180 PAYS
END, REVIEW FEES
SEE BACK OF PINK PERMIT F 311 MORE INIOPMATION
ON BEHALF OF HI S OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
THE CITY OF
;APPLICANT.
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CONSTRUCTION PERMIT APPLICATION 'AOD80HESS
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I- BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE IC
GRAD114GIFILL
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DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL IT QUIRE
SEPARATE PERMISSION.
STATE SURCHARGE,
PER IT APPLICATION: 180 DAYS
M
W I
PERMIT LIMIT. I YEAR - PROVIDED ORK S STARTED WITHIN 160 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
SUCCESORS
W, 'APPLICANT, ON BEHALFOF HIS OR HER SPOUSE. HEIRS. ASSIGNSAN
IN INTEREST. AGREES TO DEFEND AND HOLD HARMLESS THE CITY OF
LANDSCAPIN
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ED..N.E. AEH,..T.N OFF DIALS. EMPLOYEES. AND AGENTS FROM ANY AND
INSPECTION FEE
OFW ATEVER NATURE. ARISING DIRECTLYOR INDIRECTLY
ALL CIJUMS FOR DAMAGES H NOT BE
RECEIPT
FRO THE ISSUANCE OF THIS PER ISSU NCE OF THIS PERMIT SHALL
N MIT ANY REQUIREMENT OF ANY CITY ORDINANCE
DEE MEOT WAIVE OR REDUCE
01NMODIFWYAYTHE
PLAN CHECK DEPOSIT
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0 NOR LIMIT CITY'S ABILITY TO ENr PCE ANY ORDINANCE PROVISION.�
TOTAL AMOUNT DUE
RECEIPT
THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION
APPROVAL
I HEREBY ACKNOWLEDGE
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE OULY AUTHORIZED AGENT OF
T�,,1011.11�11.111 m - . P.,." u" igll�d t,l th.
T E OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
CALL BUIJ dl� 'I, , h,,r,., DOPUIY: ld F... .1. d.
EMPLOYED
TION, AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE L T
OF THE LA50A CODE OF THE STATE OF WASHINGTON RE ATtNG 0
FOR INSPECTION _.jpj i� i� Rp. .. p—,d.d.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27. -OFFICIALS SIGNATURE DATE
(425) -71 � 2,
LI RE (IN 'En al �"A' �; k)l
79E Stf _j 771.P22P R LEASEDBY DATIE I
A 'NTION EXT,333
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNT11 771-0221 -INSPECTOR
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTiFI ORIGINA.L.FILE YELLOW
CATE OF 0 UPANCY HAS BEEN GRANTEE). IJ13C SECTION 109 FAX PINK WNES GOLD -ASSESSOR
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