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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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ADDRESS
CITY ZIP
NAME
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PI.A,T NAMEISUBDIVISION NO. I LOT NO, LDN
_ LLID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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REMARKS
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FIRE REVIEWED BY DATE
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611ILDING
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PEJ_
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
D S' MA"OUEES. ETC.) WILL REQUIRE
OMAN (CURBS. SIDEWALKS. DRIVEWAY
GRADINGIFILL
SEPARATE PERMISSION. _�
S—ESTIPCIIARGE
PERMIT APPLICATION: 160 DAYS
C/
PERMITUMIT. I YEAR -PROVIDED WORK IS STARTED WITHIN iODDAYS
ENG, REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON BE HALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
IS G. INSPECTION FEE
;APPLICANT
INTEREST, AGREES TO:NDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
L-OSCAPI.G
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I E NO WASHINGTON. TSOFFICIALS, EMPLOYEES. AND AGENTS FRO. ANYAND
GIVO S
INSPECTION FEE
INSPECTION F
ALL CLAIMS FOR DAMAGES Or WHATEVER NATURE. ARISING DIRECTLIOR INDIRECTLY
-T BE
FR M THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT l"AlL NOT 5
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PLAN CHECK DEPOSIT
PLAN CH ECK
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N NOE
DEEMEDT MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANC
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D OR LIMIT IN ANYWAY THE CITY S ABILITY TO ENFORCE ANY ORDINANCE PAOVISIO
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TOTAL AM-uN
OTAL AMOUNT DUE
JRECEI�� (2
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I HEREBY ACKNOW EDGE THAT: HAVE READ THIS APPLICATION. THAT THE INFORMATION
APPLItATION APPROVAL
GIVEN IS CORRECT. AND THAT AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
CONSTRUC
THEOWNER IAGAEETO 0 LY WITH CITY AND STATE LAWS REGULATING
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PERSON WILL BE EMPLOYED
CALL
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IN VIOLATION OF THE L CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION Bpaw providod.
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL -FILE YELLOW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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PINK - OWNER GOLD - ASSESSOR
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