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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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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 GRAOINGIFILL
DOMAIN (CURB$. SIDEWALKS, DRIVEWAYS MARQUEES. ETC.) WILL REQUIRE
SEPARATE PIER�ISSION.
STATE SURCHARGE
ERMIT APPLICATION: 180 DAYS
P PERM'
PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MO E INFORMATION
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'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. ElAS. ASSIGNS AND SUCCFSORS
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INTERE AD N"Y Y OF
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I HEREBY ACKNOWLEDGE
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TION A EMPLOYED FOR INSPECTION
ASHINGTON RELATING TO
IN V1'61LAT N INE LABOR CODE 01 THE STATE OF
WDFX. S. . PENSATIONI URANCE2DRCWlA.27. 0 F CIALS SIGNATURE
DATE SIGNED (425)
DATE
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UNLAWFULTO USE OR OCCUPY ABUILDING OR STRUCTURE UNT11 L
771-0221 low'/NSPECTOR
IT IS .
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI GRIGINAL -FILE YEL
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A FINAL PINK - OWNER GOLD - A7SSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX
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SETBACKS ..................
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SPECIAL INSPECTION
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AMECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADUAGIFILL
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION,
STATE SURCHARGE
PERMIT APPLiCATI N: I.B DAYS
PERMIT LIMIT. 1 YEAR . PROVID D WORK IS ST.PTED WITIHIN '.B DAYS
E
END REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
I
;APPLICANT
D HARMLESS THE 01
N INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOL Ty OF
FRO. ANYAND
LANDSCAPING
FEE
m EDMONDS. WASHINGTONjITS OFFICIALS. EMPLOYEES. AND AGENTS
I LAI AMA E FWMAlElIEFNATUFE.ARiSING DI INDIRECTLY
ALLC MSFORD RECTLYOR INDIRECTLY
INSPECTION
REC IPT
FROM THE �.UANCEGOF THIS PERMIT ISSUANCE OF THIS PERMIT SMALL NOT BE
PLAN CHECK DEPOSIT
0 0 EYED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT .1 ANY CITY ORDINANCE -
ENFORCE ANY ORDINANCE PROVISION.
AECEIP
0 N' ILITY TO
OR LIMIT IN ANY WAY THE CITY'S AB
TOTALA OUNTDUE
t HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
5? �c_ TO
APPLICATION APPROVAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT 01
Thl, IPPI'llt'-P 11 - A I'll"t t, I Sig-d by lhb
THEOWNER I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
CALL
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71 ON. AND IN DOING T HE WORK AUTHORIZ ED TH ERE BY, NO PERSON WILL BE EMPLOY ED
RELATING TO
INSPECTIO N
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON
RCW I B.21
5
ICNATI�FE
WORKMEN 5 COM I PENSATION �EUPANCE AND
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OFFICIALS
DATE SIGNED
(425)
lu
771-0220
DATE
RECIASEDBY.,
EXT1333
ATTENTION
I IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING 08 STRUCTURE UNTIL
771-0221
W/INSPECT R
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE YEL"'
GOLD -ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK -OWNER
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