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CITY OF EDMONDS
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT CoVERSWOnK TO
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SEPARATE PERMISSION.
PE ITAPPLICATI N: 180DAYS
_LTATESURCHIRGE
PERMIT LIMIT: I YEAR -PROVIDED WORK IS STARTED WITHIN 16DDAVS
ENS. REVIEW FEES
SEE BACK OF PINK PERMIT FDA MORE INFORMATION
PLICANTo.BEHAL OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
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N INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS HE CITY OF
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ALL CLAIMS FOR DAMAGES H EVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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TOTAL AMOUNT DUE
IR CEIPT &
I HEREBY ACKNOWLEDGE THAT I HAVE HEAD THIS APPLICATION, THAT THE INFORMATION
APPLICATION APPROVAL
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WORKMEN S CoMPENI� I URANICE AN. RCVV 7.
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON T EP
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DOMAIN (CURB% SIDEWALKS. DRIVEWAYS , MAROUEES. ETC.) WILLKREU IRE
SEPARATE PER�Isslom
STATE SURCHARGE
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PE MIT APPLICATION: 150 DAYS
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PERMIT UNIT'. I YEAR - PROVIDED WORK 15 STARTED WITHIN 180 DAYS
ENG. REVIEW FEES/
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
—
-APPLICANT. ON BEHAL OF HIS OR HER SPOUSE, HEIRS. AS51GNS AND SUCCESORS
ENG INSPECTION FEE
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
LANDSCAPING
EDMONDS. WASHINGTONI. ITSOFFICIALS. EMPLOYEES. AND AGENTS FROM A,NYAND
w ALLCLAIMSFORDANAGESOFWNATEVER NATURE.ARISING DIRECTLY011 IND RECTLY
I P IT ALL NOT BE
ISSUANCE OF THIS 5RW
INSPECTION FEE
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FROM THE ISSUANCE OF THIS PERMIT.
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MODIFY, WAIVE OR RlI=EANY REGUIREMENTOF ANY C ISHORDINAN E
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PLAN CHECK DEPOSIT
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DEEMED TO
0 NOR LIMIT INANYWAYTHE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.
TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPL16ATION APPROVAL
GIVEN IS CORRECT. AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
REGULATING CONSTRUC.
Th,, nM a pej 11111 1�gled by lh8
THE OWNER I AGREE TO COMPLY WITH CITY AND STATE LAWS
PERSON WILL BE EMPLOYED
CALL
CALL
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TION.ANDIN DING THE WORK AUTHORIZED THEREBY. NO
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
pI I —
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
I SIGNATURE DATE
425)
425)
_O&IALS
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771-0220
DATE
ATTENTION
33
EXT 13;jU
lot
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE - YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. USC SECTION 109
FAX
PINK -OWNER . GOLD - ASSESSOR
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