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DevSvcs-NU-1.0-20140410
Complete this form to submit at City Hall. Or, use mybuildingpermit.com to submit your application entirely online.
Innovative - Responsive - Professional
Public Works Permit
Application
Public Works Department
For water, sewer, and right-of-way permits. This application is not required if the work will be in conjunction with a
building permit. In that case, your building permit application acts as a public works permit application.
Site Address Tax Parcel #
Description of Work to be Done:
Will this project impact or remove any significant trees?
Yes No
(If yes, see Tree Retention Checklist - Minor)
I certify under penalty of perjury that the information furnished by me is true and correct to the best of my knowledge and, further, that I am
authorized by the owner of the above premises to perform the work for which permit application is made. I further agree to save harmless the
City of Kirkland as to any claim (including costs, expenses, and attorney's fees incurred in investigation and defense of such claim), which may be
made by any person, including the undersigned, and filed against the City of Kirkland, but only where such claim arises out of the reliance of the
City, including its officers and employees, upon the accuracy of the information supplied to the City as a part of this application.
Print and Sign Date
Owner
Name
Address
City State Zip Code
Phone
Email
Contractor
A general contractor, licensed and bonded with the State of Washington, is required for work in the public right-of-way.
Name
Address
City State Zip Code
Email
Phone
License #
Applicant
Name
Address
City State Zip Code
Phone
Email
