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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PERMIT APPLICATION: 18bCAYS
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PERMIT LIMIT: I YEAR, PROVIDED Wo RK IS STARTED WITHIN 180 DAYS
E R M T L I. IT E A R P
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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- A AN HALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
AP CAEN�Ti.'�"�'EEA�LFT.'I'�CIE.NllI DEFEND AND HOLD HARMLESS THE CITY OF
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AL CLAIMS F. A.A.E OF WHATEVER NATURE. ARISING DIRECTLYORINDRECTLY
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IHERE5YA �,N LEDE THAT A�I READ THISAIPLICATION; THAT THE INIO MATION
S =T AN. THAT HE OWNER. OR THE DULY AUTHORIZED AGENT 01
GIVEN IS C. RECT AN. THAT
THEOWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONStRUC-
.DING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
TION: AND IN D
IN VIOLATION OF T.F 'LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
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WOF5N S COMPENSATION N�URANCE AN. FCW IS-21
SIGNED
APP CATION APPROVAL
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OFFICIALS SIGNATURE -AT'
(425)
771-0220
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ATTINTION
EXT/333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTI
INSPECTION BEEN MADE AND APPROVAL OR A CERTIFI_ 771-0221
ORIGINAL -FILE - YELLOW -INSPECTOR
A FINAL HAS
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109
FAX
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
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CITY OF EDMONDS
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NUMBER
CONSTRUCTION PERMIT APPLICATION
ADDRESS
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OWNER 1�!FS��UBI76
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PLAT NAMEISUBDIVISION NO.
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LID FEE
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PARKING
LOT AREA
PLANNING REVIEWED By DATE
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BIERMIT
E DONE ON �FV ATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
O.A'. 'CURSS, SIDEWALKS, DRIVEWAYS MA CUBES. ETC.) WILL REQUIRE
SEPARATE PERWISSION.
PERMIT APPLICATION; ISO DAYS
PERMIT LIVIRT. A8, ROVIDEDWOR SSTARTEDWITHiN IBODAYS
1 YE P K,
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
2 EDMONDS. WA HINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
ALL PORDAMA ESOFWHATEVERNATURE, ARISING DIRECTLYOR INDIRECTLY
CLAIMS S
ADM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMEOTOMODIFY. WAIVEOR REDUCEANY REQUIREMENTOF ANYCITYOAOINA�C
I. NORUMIT INANYWAYTHE CITY'SABILITYTO ENFORCE ANYORDINANCE PROVISION,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN 15 CORRECT. AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
THEOWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN D ING THE WORK AUTHORIZED THEREBY' NO PERSON WILL BE EMPLOYED
0
SHI
N OLAT ON OF THE LABOR CODE OF THE STATE OF WA NGTON RELATING TO
I Vi 1
WORKMENS COMPENSATION INSURANCE AND ACW 18.27,
DATE SIG NED
VALUATION I FEE
R'LAN CHECK FEE
ULDING
PLUMBING
MECHANICAL
GRADINCIFILL
STATE SURCHARGE
ENG. REVIEW FEES
ENG. INSPECTION FEE
LANDSCAPING
INSPECTION FEE
RECEIPT
PLAN CHECK DEPOSIT
I
TOTAL At. DUE
RED
_�INT
CALL
LL
FOR INSPECTION
(425)
771-0220
APPILICATIOtTA 0 1
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OFFICIALS SIGNATURE DATE
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ELEASED BY DATE
_XTTItNTION EXII-3-33 —
ITIS UNLAWFULTO USE OR OCCUPY ASUILDING 08 STRUCTURE UNTIL 771-0221
A FINAL INSIDE HAS BEEN MADE AND APPROVAL OR A CERTIFl- ORIGINAL - FILER : YELLOW - INSPECTOR
CTiON PINK - OWNE GOLD -ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX
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