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C:� CITY OF EDMONDS
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STATE SURCHARGE
PERMIT APPLICATION: 180 DAYS WITHIN 180 DAYS
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ENG. REVIEW FEES
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RECEIVED 'FINAL PROJECT APPROVAL FORM
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ENGINEFRING DIVISION
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PROPERTY TAX ACCOUNT ROEL N..
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0 RESIDENTIAL PLUMBING I MECH
ADDITION
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CHANGE OF USE
r-1 REMODEL
0 APARTMENT SIGN
0 REPAIR .
0 F_ X F_
0 GRADING CYDS
0 DEMOLISH
0 TANK o OTHER
oGARAGE
CARPORT
0 RETAI�2 WALL
130CX
0 RENEWAL
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(TYPE OF USE. BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER
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STORIES
TS
DESCRIBE WORK 10 BE DONE
LOT SLOPE %
PLAN CHECK ... IED DATE
NLY THE WORK NOTED. THIS PERMIT COVERS WORK T
THIS PERMIT AUTHO IZES
I: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
2 IVEWAYS, MARQUEES, ETC.1 WILL REQUIRE
:I DOMAIN (CURBS, SIDEWALKS, On
SEPARATE PERMISSION.
PERMIT APPLICATIO 180 DAYS
T PERMIT LIMIT, I YEAR - PROVIDED WORK WITHIN 10 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
;A PLICANT. ON BEHALF OF HIS OR HER SPOUSE, KEIRS. ASSIGNS AND SUCCESOR
NPNT9ST, AGREES TO :NDEM IFY. DEFENGOAYNED HOLNDD=LESFSRTHE CITY 0
D "' ES, A TS ANYAN
E MONGS ' WASHINGTON, TSOFFICIALS. EMP Lyoom
ALLCLAIMSFOR DAMAGESOF WHATEVER NATURE, ARISING DIRECT PINDIAECTL
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT $HALL NOT 8
DEEMED TO MODIFY, WAIVE OR REDUCE ANY EQUIREMENTOF ANYCITYORDINANC
PUT NAMEISUSE)tVISION NO.
LOT N�
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LID FEE S
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METER SIZE LINE S'll NO,OFlIXTURES
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REMARKS
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ENGINEERING E
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SHORELINE OR ADR.
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SIGN AREA
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5!5 1 ;R�IEI
LOT COVERAGE
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NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANYORDINANCE PROVISION,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
',ANDTHATIAMTHEOW� 60,,AT,,,,,,,,LYAUTHOTRl�l.IIIA.E�TOF
GIVEN ,E R
COR RECT N ST LAW FE.ULA C
I ONSTRUC.
T.EOWNER. AGREE TO COMPLY WITH CITY,
CALL
Suil Thi, appli 1 0
hi
TION� AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
OF SHINGTON RELATING TO
FOR INSPECTION
IN VIOLATION OF THE LABOR CODE OF TNE STATE
WORKMEN'S COMPENSATION INSURANCE110 RCW 18.27.
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(425)
."kqlA NAT DATE
Er DATE jr;�/
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771 -0220
EDBY AlE
ATTENTION
EXT/333
USE 08 OCCUPYABUILDING OR STRUCTURE UNTIL
771-0221
IT IS UNLAWFULTO
HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL��ILE YELLOW- INSPECTOR
A FINAL INSPECTION
OCCUPANCY HAS BEEN GRANTED. USC SECTION 109
FAX
PINK - OWNER GOLD - ASSESSOR
CATE OF
S'SE