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CITY OF EDMONDS NUMBER• (�
CONSTRUCTION PERMIT APPLICATION JOB SUITEIAPT#
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Sheet Use Permit Required ❑
CITY ZIP TELEPHONE EXISTING _ PROPOSED Inspection Required ❑
_ Sidewalk Required ❑
t/, f j ko /V T) 5 �'Q 2(? Z es Z ' 'Z REQUIRED DEDICATION _ __ FT �_ underground ❑
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO MBChanICBI
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBIC .
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Gfading
SEPARATE PERMISSION, Engr. ReVIBW
w PERMIT APPLICATION: SEE ECDC /9.00,005(A)(5)
CL PERMIT LIMIT: SEE ECDC 19,00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION Engr. Inspection
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review Plan Chk. Deposit 4-
u IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
: EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt # /
= 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 Landscape Insp. Total Amt. Due J 21
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION,*
Recording Fee Receipt #11,7
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 This application Is not a permit until signed by the
THE OWNER, I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION ; ANNN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOL •TI N OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO, FOR INSPECTION receipt is acknowledged In space provided
WORKMEN' OMPENSA ION I RANCE AND RCW 18:27, p IC S SIGNATOR DATE
SIGNATURE N GENTj: DATE SIGNED (425) �-, �--
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771 '022 RE ED BY D
ATTE' ON EXT• 1333 q
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL ��
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL . FILE YELLOW • INS ECT R
FICATE OF OCCUPANCY HAS BEEN GRANTED, UBC109) IBC110 I IRC110, PINK -OWNER GOLD • ASSESSOR
10104 PRESS HARD w YOU ARE MAKING 4 COPIES
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