980726 (3).pdfCITY OF EDMONDS INE Lee
I PERMIT NUMBER 9M FC-I'T �
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CONSTRUCTION PERMIT APPLICATION dos ITE, PTn
OWNER NAME iNAME OF BUSINESS /p ADDRESS
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•- NAME Sidewalk Required ❑ -
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This Permit covers work to be done on private property ONLY, GRAOINGIFILL -t
Any construction on the public domain (curbs, sidewalks, n
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driveways, marquees, etc.) will require Separate permission, STATE SURCHARGE
MOMMEENPermit Applicatlon: 180'Daya _
STORM DRAINAGE FEE
Permftilmit: I Year • Provided Work is Started Within 180 Days
"Aoplicant, on behalf of his or her spouse, heirs, assigns and ENG, INSPECTION FEE
in successors in interest, agrees to indemnify, defend and hold
J harmless the City. of Edmonds, Washington, its officials,
2 employees, and agents from. any and all claims for damages of
a whatever nature, arising directly or indirectly from the issuance
= of this permit. Issuance of this permit shall not be deemed to PLAN CHECK DEPOSIT v
° modify, waive or reduce any requirement of any city ordinance
x° nor limit in any way the City's ability to enforce anyet)rdinance ����p�
provision."
TOTAL AMOUNT DUE
I hereby acknowledge that I have read this application; that the ATTENTION APPLICATION APPROVAL
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 THIS PERMIT This application is not a permit until
state laws regulating construction; and in doing the work authorize AUTHORIZES
ed thereby, �90 person will be employed in violation of the Labor ONLY THE signed by the Building Official or his/her
Code ofthio late of Washington relating to Workmen's Compensa• WORK NOTED Deputy; and fees are paid, and receipt is
tion lnsur rice aria RCW 18.27, INSPECTION acknowledged in space provided.
SIGNATURE OWNER OR AGENT) DATE SIGNED DEPARTMENT
s� _,�_.__ 1 q -^� CITY OF OFFICE L' NAT SDA
---- -- _ a �f QL EDMONDS
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CALL FOR REL Y DATE
ATTENTION INSPECTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE ��� o��o
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR ORIGINAL — Flle YELLOW— Inspectoa.
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED, UBC
SECTION 109 PINK — Owner GOLD — Assessor
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