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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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REVIEWE Y DATE J
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RED PROVIDED
7 I� P-ERMIT L(OVERS WORK TO
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. TH
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 HIN 180 DAYS
PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WIT
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPi ICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND sUCCESORS
INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
IN! DN ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
EDMONDS. WASHINGT( ' lHiCTLY OR INDIRECTLY
EVEH N� �HA'
L�A A AGE F 'AT UHL'
0 W' ERMT SS UANCE OF THIS ITY
IS P C ol
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING D pFRMIj SHALL NOTBE
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FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS I
r Y U
M W V 0 R j C N R a IRE ME NI OF ANY Cr
R E E A' Y REQUIREMENT OF ANY CITY ORDINANCE
DEEMED TO MODIFY,�WAIVE OR REDUCE AN AN Pf
CITYS OILITY 1 0 _ �o RC ANY ORDINANCE PROVISION. -
Noll LIMIT IN ANY WAY THE CITYS ABILITY 10 ENFORCE ANY
IA, Tj IF: I
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-
E WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
TION; AND IN DOING TI I A13OR CODE OF THE STATE OF WASHINGTON RELATING TO
IN VIOLATION OF THE L
WORKMEN'S COMPENSATION INSURANCE AND RCW 16 27.
UR (OWNE OR DATE SIGNED
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OCCUPANT
SPECIAL INSPECTION AHl_A LOAD
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REMARKS FS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D 1 -4
- . . . I . _�n A , ow I 121 C,-eA R
VALUATION
$ 24-?,e2l
/�2'z
Description
Plan Check
Building Permit
plumbing
Mechanical
Grading
WEngr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
FEE Description FEE
17 State Surcha
City Surcharge
Base Fee
CALL
FOR INSPECTION
(425)
771-0220
EXT 1333
Plan Chk. Deposint
Receipt
Total Amt. Due
LA
Receipt N , I -,! ZZI 2 42
APPLICATION APPROVAL
This application is not a permit until signed by the
Building oflicial of his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
FFICIA 'GN� HE DATE
v
I EIASED BY I
ATTENTION R OCCU13Y A BUILDING OR STRUCTURE UNTIL LL—"
IT IS UNLAWFUL TO USE 0
N HAS 13EEN MADE AND APPROVAL OR A CERTIFI-
A FINAL INSPECTIO AS 13EEN GRANTED, UBC SECTION 109 KING 4 COPIES
CATE OF OCCUPANCY H PRESS HARD -YOU ARE MA
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