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USE PERMIT
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CONSTRUCTION PERMIT APPLICATION JOB UITUAPTR
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DATE
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THIS PERMIT AUTHORP�E ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADI—FILL
2 DOMAIN (CURBS. SIDEWALKS. DRIVEWAYS , MARQUEES, ETC.) WILL REQUIRE
M SEPARATE PERMISSION.
STATE SURCHARGE
MIT APPLICATI 0 : ITO DAYS
YEPE
A. PERMIT LIMIT'. AR. PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
;APPLICANT.
N INTEREST. AGREES TO INDEMNIFY. DEPEND AND HOLD HARMLESS THE CITY OF
I
I - OM ANY AND
I EDMONDS. WASHINGTON. ITS OFF DIAL E PLOYEES. AND AGENTS FR
S NAMTURE, ARISING DIRECTLY OR IN.IRECTLY
ALLCILAIMS FOR DAMAGES OF WHATEVER
INSPECTION FEE
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PLAN CHECK DEPOSIT
DEEMEDTO MODIFY, WAIVE OR REDUCE ANY R QUIREMENTOFANYCIIYORDINANC
E E
0 IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.
NORLIMIT
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATI N
GIVEN IS CORRECT: AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
THE OWNER, I AGREE To COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
CALL
TION AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON W' ILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RE LATING TO
FOR INSPECTI,
WORKMEN'S,COMPEN$�TION INSURANCE AND RCW 18.21.
_7E SIGNED
(425)
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771-0220
ATItNTION
EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
VALUATION I FEE
APPLICATION APPROVAL
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MECHANICAL
THIS PERMIT AUTM.RIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
11 DONE I" PRIVATE PROPERTY ONLY. ANY 1111"UITION ON THE PUBLIC
GRADINGIFILL
OMAtN (CURBS. SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
STATE SURCHARGE
PERM T APPLICATION: 180 DAYS
PERMIT LIMIT,. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEESAC K OF PINK PERMIT FOR MORE INFORMATION
A PP ICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
t
IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
I EDMONDS. WASHINGTON, ITS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANYAND
INSPECTION FEE
A AT
ALLCLAIMS FOR DAMAGESOF WHATEVE N URE. ARISING OIRECTLYOR INDIRECTLY
PERMIT. SSUANCE OF THIS PERMIT SMALL NOT BE
I
ROM THE ISSUANCE OF THIS
DEEMED 0 MODIFY, WAIVE OR REDUCE ANY REQUIREMENTOF ANY CITY ORDINANCE
T
NOR LIMIT IN ANY WAYTHE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.
TOTAL AMOUNT DUE
IRECEIP;/ fo,36 r7a S70
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION. THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN I CORRECT. AND THAT I AM THE OWNER. OR THE DULy�,UTHoTllNl.ED AGENT OF
TI, � .1pl-l- I. , -1 - P 1 41 .19- by Ih.
E.U, CO.
THEOWNUR I AGREE TO COMPLY WITH CITY AMD STATE LAW STRUC-
CALL
S.,Idima 011,111, 11 1,11me, 01 IY%,,dF ond
TION, AND IN DOING THE WORK AUTHOR, ED THEREBY, NO PERSON WILL BE EMPLOYED
WASHINGTON RELATING TO
FOR INSPECTION
ip- Ilk,,Wlodg % I . .... pm,d,d.'d'
IN VIOLATION OF THE LABOR CODE OFZTHE STAT E OF
WORKMEN'!�COMPEN:��=RANCE AND RCW 1 .27.
ALE SIGNATUR T
SIGNAl ENT) DATE SIGNED
(425)
I /
f I I -ur."
Fb"LU by
4T;ftNTION
EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL- FILE YELLOW - INSPECTOR
A FINAL
CATE OF OCCUPANCY HAS BEEN GRANTED. LIBC SECTION 109
FAX
PINK -OWNER GOLD ASSESSOR
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