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THIS PERMIT AUTHORIZES ONLY THEWORK NOTED. THIS PERMIT COVERS WORK TO
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BE DOME ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE B
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DOMAIN tCURBS, SIDEWALKS, DRIVEWAYS, MAII00168, ETC.) WILL REQUIRE
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SEPARATEPERMISSION.
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Engr. Review City Surcharge 5
PERMITUMITI PERMUTAPPLICATION INDAYS
YEAR - PROVIDED WORK IS STARTED WITHIN INDAYS
Engr. Inspection State Surcharge
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
GENA F
'APPLI NTONGENA OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
Traffic Mitigation Plan Chk Deposit
IN INTEREST AGREE TO INDEMNIFY, DEFEND AND HOLD HARM ESS THE CITY OF
EDMONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
Fire Review
FROM THE I SUANCE OF IS PEAMM ISSUANCE OF THIS PERMIT SHALL NOT B
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY C TY ORDINANCEE
Fire Inspection Total Amount Di
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NOR LIMIT IN AM WAY THE CITYE ABILITY TO ENFORCE ANY ORDINANCE PROVISION.4
Landscapoinsp. I Receipt #
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
GIVEN IS CORRECT., AND THAT I AM THE OWNER, OR THE Duty AUTHORIZED AGENT OF
APPLICATION APPROVAL
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL application is not a permit until signed by Me
TION; AND IN DOING THE WORK AUTH RIZED THEREBY, NO PERSON WILL BE EMPLOYED
0
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN' I N I SURANCE AND HOW 18.21,
StiliThis
ding Offlatal,r league Deputy: and Fees are paid. and
FOR INSPECTION fecolpt Is acknowledged 11 space provided,
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a NATURk=EB DATE
MIIGN�TURE DATE -7j/�
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771-0220 DATE
BY
ATTENTION
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IT IS UNLAWFUL To USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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FAX PINK -OWNER GOLD -ASSESSOR
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