820197.pdfUSE
CITY OF EDMONDS 20NE I ^ NUMBER
CONSTRUCTION PERMIT APPLICATION ,Da X/
�_ _ NAME TOR NAME OF BUSINESS) ADDRESS
820197
[PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
XISTING REQUIREU DEDICATION
ROPOSEDIGHT OE WAY CONSTRUCTION PE II REOUIREOTREET USE PERMIT REQUIREDEE ENGINEERING MEMOEE PIW DEPT REVIEW CHECK LIST DATED
SIGN AREA ENV. REVIEW ADB NO. rl
ALLOWED I PROPOSED COMPLETE I EXEMPT
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GROUP
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UNITS
NATURE OF WORK TO BE DONE (ATTACH PLOT PUN)
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PLAN CHECK FEE
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MECHANICAL
This Permit covers work to be done on private property ONLY.
Any
GRADINGIFILL
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construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission.
Permit Application: 180 Days
Permit Limit: 1 Year- Provided Work Is Started Within 180 Days
"Applicant, on behalf of his or her spouse, heirs, assigns and
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Successors in interest, agrees to Indemnify, defend and hold
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harmless the City of Edmonds, Washington, Its officials,
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employees, and agents from any and all claims for damages of
whatever nature, arising directly or Indirectly from the Issuance
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of this permit. Issuance of this permit shall not be deemed to
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modify, waive or reduce any requirement of any city ordinance
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noT limit in any way the City's ability to enforce any ordinance
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TOTAL AMOUNT DUE
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
ATTENTION
APPLICATION APPROVAL
state laws regulating construction; and In doingthe work authoriz-
ed thereby, no person will be employed In violation of the Labor
THIS PERMIT
AUTHORIZES
s application lication is not a permit until
Code of the State of Washington relating to Workmen's Compensa-
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ONLY THE
WORK NOTED
signed by the Building Official or his
Deputy; and fees are paid, and receipt Is
n Insurance.
T IOWNER OR ADE DATE
INSPECTION
acknowledged In space provided.
-J/ SIG -D
DEPARTMENT
CITY OF
OFFICIAL'S SIGNATURE
THIS SITE IS LOCATED IN THE CITY
EDMONDS
Ct / 1Ck4ti`4.2—
LOCAL TAX
ATTENTION SHOULD BE CODED OF EDMONDS.
775.2525
DATE
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
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ANTIL CERTIFICATEA FINAL INOFECTION OCCUPANCY HAS BE
CCUPACYBEEN HAS ABEENDE N GRANTED. APPROVAL
UMAy 1982 ORIGINAL —File YELLOW —Inspector
CHAPTER 3.
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102 78
PINK — Owner GOLD -- Assessor
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