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S EPAR ATE WEAF MI S SI ON.
STATE SURCHARGE
PERMIT APPLICATION: 180 DAYS
A. PERMIT LIMIT'. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT Pon MORE INFORMATION
ENG.nEVIEW FEE
1 PLICANT. ON BEHALF OF HIS 08 HER SPOUSE. HEIRS, A-1—
IN P INTEREST, AGREES TO :NDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, TS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRSCTLY
F80M THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMEDTOMODIFY, WAIVEORITEDUCEANY REQUIREMENT FANY CITY ORDINANCE
'OR LIMITIN ANYWAYTHE CITY'S ASILITYTO ENFORCE ANY ORDINANCE PROVISION.-
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I HEREBY ACKNOWLEDGE THAT' HAVE READ THIS APPLICATION: THAT THE IN FORMATION
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
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND ACW 18,27.
CALL
F -0 R INSPECTION
APPLICATION APPROVAL
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771-0220
7
DATE
Ai:i�§FTION
EXT 333
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
FINAL INSPECTION HA S BEEN MADE AND APPROVAL OR A CERTIFI-
771-0221
ORIGINAL�FIL YELLOW - 'INSPECTOR
A
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK -OWNER GOLD - ASSESSOR
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