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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP AW Perm" Requited 0
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CITY ZIP TELEPHONE EXISTING — PROPOSED Inspection Required 113
Sidewalk Required 0
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS. WASHINGTON . ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT; AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATIMCIKOQANCE AND RCW 18.27.
DATE SIGNE
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
5/98
VALUATION
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TOTAL AMOUNT DUE RECEIPT
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APPLICATION APPROVAL
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This application is not a permit until signed by the
Building Official or hisiher Deputy: and Fees are paid. and
FOR INSPECTION
receipt is acknowledged in space provided.
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0 93,01 22,:�) 5yl pt4 1. Street Use Prinnit Req'd E3
CITY ZIP ITELEPHONE EXISTING — PROPOSED Inspection Required 0
Sidewalk Required 0
REQUIRED DEDICATION— FT Underground
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NAME METER SIZE LINE SIZE NO, OF FIXTURES PRV REQUIRED
YES 0 NO 0
ADDRESS REMARKS
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC GRADING/FILL
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
:3
SEPARATE PERMISSION.
SXArr6URCHARGE
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS ENG. REV:IEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
tMG. INSPECTION FE
APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
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EDMONDS. WASHINGTON, ITS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANY AND INSPECTION FEE
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY RECEIPT
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE PLAN CHECK DEPOSIT
DEEMED TO MODIFY, WAIVE OR REDUCEANY REQUIREMENT OF ANY CITY ORDINANCE
x 0 NOR LIMIT IN ANYWAYTHE CITY'SABILITYTO ENFORCE ANY ORDINANCE PROVISION.* RECEIPT
I TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Fees are paid. and
IN VIOLATION OF THE LASO8..Q0DE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged In space provided.
WORKMEN'S COMPENSADrR"ANCE AND RCW 18.27. OFFIPAL GNA 6�RE DAT�
SIGN W V0 Ab DATE SIGNED (425)
6121119?
771-0220 ELE ED BY DAT
ATTENTION EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL - FILE - YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX PINK - OWNER - GOLD - ASSESSOR