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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NA EINAME OF BUSINESS
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MAILINGADDRESS
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STATE LICENSE NUMBER
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VALUATION FEE
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SLOPE %
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PLUMBING
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T.IS.PERITAUTHORIIEESONIT��Wo�K..TF... THIS PERMIT COVERS WORK TO
CONSTRUCTION ON THE PUSUC
E DONE N PINVAT PROPERTY ONLY. ANY
SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
GRADINGIFILL
DOMAIN (CURBS,
n SEPARATE PERMISSION
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STATE SURCHARGE
P SMIT APPLICATION: ISO DAYS
E
0 IS ]THIN 180 DAYS
PERMIT LIMIT. I YEAR � PROVIDED W RK STARTEDW
ENO. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFO MATION
;APPLiCANT. ON BEHALF OF HIS OR HER SPOUS5. HEIRS. ASSIGNS AND SUCCESORS
H RIM HE CITY OF
EFEND AYEEECLND A LESS T
ENG. INSPECTION FEE
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2 EDMONDS, WASHINGTON TS S.EMPLO A
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY.R
ISSUANCE OF THIS PERMIT SHALL OT BE
FECEIP
PLAN CHECK DEPOSIT
FRO THE ISSUANCE 01 THIS PERMIT.
M ED I
DEEMEDT MODIFY. WAIVE OR REDUCE ANY R U HEMENTOF ANY CITY ORDINANCE
No 0 yTC NFORCE ANY ORDINANCE PROVISION."
R LIMIT IN ANY WAY THE CITY'S ABILIT E
TOTAL AMOUNT DUE
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR T.HE DU�Ly�AUTHDRI�I.IG AGENT OF
Th-111-1— �.d b,
STAT LAW " I', CON
T EOWNIR I AGREE TO COMPLY WITH CITY AND STRUC.
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N VIOLATION OF THE LABOR CODE OF THE STAT
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OFF IALS SIGNATURE DATE
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(425)
OL,,
771-0220 RELEASED By
EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTI
L
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI.
ORIGINAL - FILE YELLOW � INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX PINK OWNER GOLD -ASSESSOR
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LOT NO-
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YES 0 NO
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DATE
,TATE LICENSE NUMBER EXPIRATION DATE I CHECKED By
SERA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED P�107
ROPERT'Y TAX ACCOUNT PARCEL NO.
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LOT COVERAGE REQUIRED SETBACKS (FT.3 PROPOSE D SETBACKS (FT.)
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A LOWE OPOSED ONT SIDE REAR FRON UR
COMPLIANCE OR
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
8.E.DAONE(ONP.11�VATIR.P�RII.�LY.A�YC.N.RUCII...�T.�1U.L,C
CUR . SIDEWALKS. DRIVEWAYS , MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PLUMBING
MECHANICAL
GRADING/FILL
STATE SURCHARGE
E MIT APPLICATION: '-- DAYS
P R
PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ENG. REVIEW FEES
�Ap I PLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
N NTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON. ITS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANYAND
,,, A L CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING OIRECTLYOR INDIRECTLY
'b L
[FAOM THE jISSUANCE OF THIS PERMIT. SSUANCE OF THIS PERMIT SHALL NOT BE
Q
, DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.
ENG. INSPECTION FEE
_.Dss�
lNeP6GWN F
PLAN CHECK DEPOSIT
TOTAL AMOUNT DUE
RECE176 A/I 9�
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORVATION
GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE Toc III EGULATING CONSTRUC-
oMPLY WITH CITY AND STATE LAW 'R
TtON; AND IN DOING I HE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOY ED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON BELA . TIN. To
WORKMEN S COMPENSATION INSURANCE AND RCW 18.21.
sir TU C ATE SIGNED
APP��
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Thl, 1 , piftit u,ntil 11g by th,
CALL ... ...
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FOR INSPECTION bbip � �p ... p—d.b.
7. FT� �SSIGN UR� DATE
(425) - !FIA� ,
7 -0220 DATE
71 R ELEA.Eo BY
AFENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
HAS BEEN MADE AND APPROVAL OR A CERTIFI-
EXT 333
771-0221
1 f_4_�
ORIGINAL - FILE YELLOV� - INSPECTOR
A FINAL INSPECTION
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK - OWNER GOLD - ASSESSOR
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