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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
CITY ITELE HONE
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NAME
ADDRESS
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NAME
ADDRESS
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PERMIT
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REMARKS
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T THIS PERMIT AUTHORIZES ONLY TIE WORK NOTED, THIS PERMIT COVE'S WORK TO
HIS PERMIT AUTHORIZE' 0 NLY T HE Wo"
BE ONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Ty
BE DON' ON PRIVATE PROPE R ONLY
GRADING)FILL
DOMAIN 'CUP.S. SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
DOMAIN (CLIFFS SIDEWALKS ' OR
SEPARATE PERMISSION.
SEPARATE P
STATE SURCHARGE
PERMIT APPLICATION: 100DAYS
PERMIT APPLOATI
P IN 180 DAYS
PERMIT LIMIT: 1 YEAR. ROVIDED WORK IS STARTED WITH
PERMIT LIMIT ' Y EAR _ PROVIDED W.
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
SEE SAC . OF PINK PERMIT,
ASS'. NS AND EU-CESORS
PLICANT. ON BEHAL OF HIS On HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
APPLICANT ON - E�AL' OF HIS OR HER S,
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ENG LINSPECTION FEE
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N INTEREST, AGREES TO :NDEMNFY. DEFEND AND HOLD HARMLESS THE CITY 01
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AND AGENTS FROM ANYAND
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I EDMONDS, WASHINGT N� TS OFFICIALS, EMPLOYEES,
E .. NDS WASHINGTON ITS OFFICIALS I
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INSPECTION
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ENFORCE ANY ORDINANCE PROVISION
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N R I IN N A HE AWL,
T OUNT DUE
READ THIS APPLICATION. THAT THE INFORMATION
APPLICATION APPROVAL
I HERE Y ACKNOWLEDGE THAT I HAVE
6 ED T
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GIVEN IS CORRE AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
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IT
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
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A FINAL
CATE OF OCCUPANCY HAS BEEN GRANTED. USC SECTION 109
FAX
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I G P "-M IT A .T. on 'ZE. ONLY T. W
a DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
t_ E GRADINGIFILL
A E R E .L - AN'
E DO E ON p ' T P - ' -TY
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DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES. ETC.) WILL REQUIRE
.-AN ICU BE EWALKS ' R
T. PER.
SEPARATE PERMISSION.
PARA STATE SURCHARGE
FHEAT
PERMIT APPLICATION: TOO DAYS
'.AT'..
Won K I
PERMIT LIMIT'. I YEAR " PROVIDED WORK IS STARTED WITHIN 180 DAYS ENO. REVIEW FEES
T L N
IT FOR I
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
C
ENG. INSPECTION FEE
0
w ;AP , PLICANT. ON BEHALF OF HIS OR HER SPOU 'BE, HEIRS. ASSIGNS AND SUCCESORS
:NDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF LANDSCAPING
R S OR S T I M I Y UE
N INTEREST. AGREES TO
I EDMONDS, WASHINGTON TS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANY AND IN SPECTION FE E
BMO US H To I I., LS M
LL CLAIM FOR A.A.E OF WHATEVER NATURE. ARISING DIRECTLY On INDIRECTLY RECEIPT
A R.. T. U FIMR IS U
!.5 ���I�,SITSRIAINACAGEF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE PLAN CHECK DEPOSIT
0 E . D TO MODIFY WAIVE OR REDUCE ANYR� OF ANY CITY ORDINANCE
0 E E . E'UTY To 0 RECTP
N P L .. T I N ANY WAY THE �,TY S A El RDINANCE PROVISION. TOTAL AMOUNT DUE
_1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF Th,, pplt,,([,, nt not a permlt 1 �lgn.d ol In,
HE NI IAGREE To COMPLY WITH CITY AND STATE LAWS REGULATING CONITRUC" CALL Build,ng 011i,ial to,thor D.,I, nd F — o. no
T OW
DOIN T. OR. AUTHORIZED THEREBY' No PE ASOM WILL BE EMPLOY ED n—ipl
- E W WASHINGTON RELATING TO FOR INSPECTION
T N.AN 1 0
IN VIOLATION 0, THE LABOR CODE OF THE STATE F
W ... �.,. C .. EN.ATION IN SURANCE AND RCW 18.27. 7.11AL..IG 0 DATE
7Ty,NER,AR AD Ey� DATE SIGNS (425)
-1-7-/6 771-0220 RILEASED BY PrATE
'4 4NN wt, c:
TI EX11333
A __J
i IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL -0221 1
I PROVAL OR A CERTIF 771
A FINAL INSPECTION HAS BEEN MADE AND AP I- ORIGINAL - FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX PINK OWNER COLD -ASSESSOR