20050767.pdfFDATE �RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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PROPERTY TAX ACCOUNT PARCEL NO.
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER
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PLAN CHECK NO; VESTED DR it:
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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.
W PERMIT APPLICATION: 180 DAYS
EL PERMITLIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
-SEE BACK OF PINK PERMIT FOR MORE INFORMATION
OAPPLICANT, 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
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
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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 C90PNSATION INSURANCE AND RCW 18.27.
DATE SIGNED
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VALUATION
$
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
CALL
FOR INSPECTION
(42,15)
771-0220
EXT 11 _rA 1
FEE rDescription FEE
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State Surcharge q, 1576
City Surcharge
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ase Fee C�'
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PlanChk.Deposit ML:U
Receipt #
Total Amt. Due
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Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receipt Is acknowledged in space provided.
-FIC"I SloNAT E DATE
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REL
IT IS UNLAWFUL TO USE OR OCCU�Y 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
09/03
PRESS HARD -YOU ARE MAKING 4 COPIES
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1653 E.MPIN STREET
ROCHESTER, NY 14609
TEL (716) 482-0300
FAX C716) 288-5989
Precision llVL4GE Products & Services
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Micro Com, Systems Ltd.
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