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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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THIS PERMIT AUTHORIZES ONLY THE W.-B( NOTED- THIS PERMIT COVERS WORK TO
I BE DONE ON PRIVATE PROPERTY ONLY� ANY CONSTRUCTION ON THE PUBLIC
GRADINGIFILL
5 DOMAIN (CURB% SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
1. SEPARATE PERMISSION,
STATE SURCHARGE
RE APPLICATION� 180 DAYS
AERMIT
PERMIT LIMIT, I YS ' PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG, REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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'APPLICANT, ON BEHALF OF POUS . HEIRS, ASSIGNS AND SUCCESORS
H':1ofREY`7 'FSADEXN.
IN INTEREST, AGREES To NO , DIE HOLD HARMLESS THE CITY OF
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FROM THE ISSUANCE OF THIS
D T Fy, WAIVE OR R5DUC5 NYREOUIREMENT OF ANY CITY ORDINANCE
5EMED OMODI
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TOTAL AMOUNT DUE
RECEIPT
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I HEREBY ACKNOWLEDGE THAT I HAVE REA THIS APPLICATION� THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN S CORRECT. AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
1V 1 ��glld by Ih,
THE OWNER, I AGREE TO DO AND STATE LAWS REGULATING CONSTRUC-
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CALL
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TION, AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
WASHINGTON RELATING TO
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FOR
IN VIOLATION OF THE LABOR CODE OF THE STATE OF
WORKMEN S COMPENSATION INSURANCE AND RCW 18.21 —
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OFFICIA ME DATE
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ATTENTION
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771-0221
FINAL INSPECTION HAS BEEN MADE A ND APPROVAL OR A CERTIFI�
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ENGINEERING DIVISION DATE-
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PLANNING DIVISION DATE
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DESCRIPTION OF WORK TO BE INSPECTED
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A field inspection was conducted to determine compliance with approved plans. Final approval denotes that
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there are no objections from the above signed Department to the granting Of:
Final approval ofthe described work
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GRANT FINAL PROJECT APPROVAL
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PROJECT APPROVAL WITH CONDITIONS NOTED
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES RECEIVED
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ONG, REVIEW F,5ES
SEE BACK OF PINK PERMIT FOR MN INZWMIATION
F HI OR HER POI HEMS� ASSIGNS AND SUCCESORS
AIT�ON.SEHALFT S S
;AF'PLICA ONSEHALF
A R E. FY, DEFEND AND HOLD HARMLESS THE CITY .1
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BE
INSPECTION FEE
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x FROM THE ISSUANCE OF THIS PERMIT. SSUANCE OF THIS PERMIT SHALL NOT
PLAN CHECK DEPOSIT
P P� DEEM90T EORREDUCEANY OUIREMENTOF ANY CITY ORDINANC�
O"C""'"AIV PROVI
_ To MOD' 'S TOREHFORCE ANY ORDINANCE SION.
RECEIPT
TINANY ABILITY
NORLIMIT WAYTHECITY
TOTAL AMOUNT DU E
HERE BY ACKNOWLEDGE THAT ('�AVi READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION A 50 L
IS CORRECT, AND TH 0 AUTHORIZED AGENT OF
GIVEN AT I AM THE OWNE86 OR THE I ULY
TO COMPLY WITH CITY AN STATE LAWS REGULATING CONSTRUC
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CALL D. I �O
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THE OWNER. I AGREE
TION; AND IN DOING THE WORK AUTHORIZED THERZSY6NO Pe FISCH WILL BE EMPLOYED
RELATING TO
I
I- O-R INSPECTION 7-1- 21222" T 222 p"""'
IN VIOLATION OF THE LABOR CODE OF THE STATE F WASHINGTON
CWIB.27.
ON U E DATE
WORKMEN'S COMPENSATION INSURANCE AND
ATE SIGNED
OFFICIA
(425)
(I 2_0 - OC)
.1 771-0220 RCLEA ED BY
ATTENTION
EXII 333
OR STRUCTURE UNTIL
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING 771-0221 INSPECTOR
FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL.,FILE - YEL LOW
- GOLD - ASSESSOR
A
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX PINK - OWNER