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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTEM THIS PERMIT COVERS WORK TO
T I. ' E P. IT AU 'ZES N-R
ON PRIVATE PROPERTY ONLY. AN' CONSTRUCTION ON THE PUBLIC
N G N A Y LY ANY .N.,R -CT'ON ON THE PUBLIC
. E P-IV T. P R.
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Y `DUEES ET. WILL R ED t..
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES. ETC.) WILL REQUIRE
A SL DEWA' 'EWA S. MA
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PER-,S�'--
SEPARATE PERMISSIO-
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STATE SURCHARGE
E SURCHARGE
I. YS
PERMIT APPLICATION: 180 DAYS
A. P S T W, Y
PERMIT LIMIT� I YEAR. PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
REV F
SEE BACK OF PINK PERMIT FOR MORE INF DRMATION
PPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS A- SUCCESORS
A G N G G R S , C Y F
A M'E S HE IT 0
TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY 01
F TI N
LANDSCAPI JG
LAN-SCA P' J.
N NTEREST� AGREES
C N.S 0 ITS _S P Y S AN. A -ENT , F Ro. ANY A -
EDMONDS,WASHINGION, ITSOF CIALS. EMPLOYEES, AND AGENTS FRO. ANY AND
F, E. L. EE
INSPECTION FEE
N P E T N ` E
�R I CN Y
ALL CLAIMS FOR DAMAGES OF WH El RNATUPE,ARIStNGDIR CTL RINDIRECILY
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L GLAMS R AT E G, ECTLY OR ..'RE '
M G OF S G , E
PS S L L
FROM THE ISSUANCE 01 THIS AMIT. ISSUANCE OF THIS PERMIT S.ALL NOT BE
AN E
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PLAN CHECK DEPOSIT
Mo I Y W IV R MENT OF ANY CITY GROIN
DEEMED T MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY RDINA
0 F A E ANY PE.U' E
0
DEEMED 0 AN SION
T To , 0 C Y 0. C E PROVSON
ABILITY TO ENFORCE ANY ORDINANCE PRO'
Y W Y T. CL,
NOR UNIT IN ANY W.AY THE CITY 5
IMI T
TOTAL AMOUNT DOE
iHEREBY ACKNOWLEDGE THAT I HAVE HEAD THIS APPLIGATION� THAT THE INI.RMATI-N
GIVEN IS CORRECT, AND THAT I AM THE OWNER. A;HE qUSLRTHOFlNZG�O AGENT .1
CITY AND ST E LAW EGULAT CON STRUC
CALL
THE OWNER I AGREE TO C.MPLY WITH
P 0
TION. AND IN DO NG THE WORK AUTI-LORIZED THEREBY. NO PERSON WILL BE E. L.yE
RELATING To
FOR INSPECTII
IN VIOLATION O'F THE LABOR CODE OF THE STATE OF WASHINGTON
WORKMEN S COMP SA NRANCE AND RCW 1 B,27
DATE SIGNED
(425)
771-0220
AtTENTION
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-
HAS BEEN GRANTED. UBC SECTION 109
FAX
CATE OF OCCUPANCY
VALUATION I FEE
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