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[PLERMIT EXPIRES
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CITY OF EDMONDS NUMBER
CONSTRUCTION PERMIT APPLICATION JOB T�/AFT#
ADDRESS
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REMARKS
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION O",THE PUSLIC GRADINGIFILL
DOMAIN (CURDS, SIDEWALKS, DRIVEWAYS, MARQUEES , ETC�) W LLRE DIRE
SEPARATE PERMISSION,
URCHARGE
PERMITAPPLICATIO i IGO DAYS
PERMIT LIMIT. I YEAR. PROVIDED WORK IS STARTED WITHIN 18D DAYS ENO, REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
;APPLICANT ON BEHAL 0 HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS ENG. INSPECTION FEE
N INTEREST, AGREES TO:NDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF SCAPI.G
TS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANY AND INSPECTION FEE
OF WHATEVER NATURE. ARISING DIRECI LYOR INDIRECTLY RECEIPT
NOT BE
; PERMIT SHALL PLAN CHECK DEPOSIT
OFANY CITY ORDINANCE
ORDINANCE PROVISION.' HE EIPT 0,ob
TOTA OUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AFPLICATJON� THAT THE INFORMATION APPLICATION PPROVAL
OUL
GIVEN IS CORRECT: AND THAT I AM THE OWNER, OR THE _ AUTHORIZED AGENT OF .1" �jl .�Ijl ��gd ly
'I R ' STATE LAWS REGULATING CONSTRUC- CALL
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IN V"6LATION OF THE LABOR CODE OF THE STATE OF WA HINGTON
AND RCW 18.27� E DAT,�
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WORKMEN'S COMPENSATION INSURANCE OP
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OAT SIGNED (425)
5110 ATURE (OWNER
/1, 1 771-0220 PLEASED By
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EXT1333
ATTENTION AA CA _p,
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221 INSPECTOR
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- OAIGINAL - PILE - YELLOW,
. ASSESSOR
A FINAL
HAS BEEN GRANTED. USC SECTION 109 FAX PINK - OWNER - GOLD
CATE OF OCCUPANCY
5me
INSPECTOR
DATE APPROVED
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SETBACKS .....................
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SPECIAL INSPECTION
MISCELLANEOUS ..........
FINAL APPROVAL FOR
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F
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SEPARATE PERMISSION.
UITCHARGE
PC MITAPPLICATION: 1800AYS
PE.
IT L PROVIDED ORKIS STARTED WITHIN 180DAYS
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PERMIT LIMIT� I YEAR
ENG, REVIEW FEES
'
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
KOF
rTHIS
ON BEHALF OF HIS OR HER SPOUSE. HEIRS, AS 1 9 AND OtSORS)
P T S ALF OF
E)qG.IINSFECTION FEE
;APPLICANT,
N NT5REST. AGREE TO:NOEMNIFY. DEFEND AND HOLD LESS H CITY OF
, R S
IN' T S
I ANYAND
LANDSCAP NO
0 DS WASHINGTON ITS OFFICIALS, EMPLOYEES. AND ENTSFROM
I EDMONDS�WASHINGT" E
AGE OFWHATEVEFI NATURE. ARISING
ALLCLAtMSFORDAM CTLYORINDIRECTLY
L CLA M. 0 MAD
PERMIT SHALL NOT BE
INSPECTION FEE
RECEIPT
Aa L,
uu
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS
E M To Mo "Y W DINANCE
DEEMED TO MODIFY. WAIVE OR REDUCE ANY RSQUIRCMENTOI ANY CIT"OR
PLAN CHICK DEPOSIT
11
I
0 R T IN AN A HE' ITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
0 0 L M Y W Y T
NOR LIMIT IN ANY WAY THE C
TOTAL AMOUNT F
R E
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION, THAT THE INFORMATI N
APPLICATION PPROV L
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
P81ml u�tll 11910d bY thO
TIP,, ppll,on �, It I
THE OWNER. I AGREE TO COMPLY WITH CITY AID STATE LAWS REGULATING CONSTRUC-
CALL
G ePutTIIdF.Mp,,d.,,d
TION; AND IN DOING THE WORK AU HORIZED THEREBY, NO PERSON WILL BE EMPLOYED
WASHINGTON RELATING TO
FOR INSPECTION
.... pI,kIIdg.d,,, p— p'—III.
IN VIOLATION OF THE LABOR CODE OF THE STATE OF
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
OFR�Al_. SI...AT.FE DArf,
(4251
J_? , — '7 71
,��GTJI OWNER &-I
771-0220 LEASED BY
ATTENTION EXT1333 UA h
IT IS UNLAWFUL TO USE 01, OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221 ORIGINAL - FILE - YELLOW - INSPECTOR
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- PIN
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109 FAX K � OWNER - GOLD - ASSESSOR