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1140 A AVE S
ADDRESS: I NO A kupGci
TAX ACCOUNT/PARCEL NUMBER (�
BUILDING PERMIT (NEW STRUCTURE): I " l O, U 7j
COVENANTS (RECORDED)
CRITICAL AREAS:
DISCRETIONARY PERMIT #'
DRAINAGE PLAN DATED:
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED:
SEWER LID FEE $:
SHORT PLAT
SIDE SEWER AS BUILT DA
SIDE SEWER PERMIT(S) #:�
GEOTECH REPORT DA
STREET USE / ENCROACHMENT PERMIT
WATER METER TAP CARD DATED:
OTHER:
DETERMINATION: ❑ Conditional Waiver. ❑ Study Required ❑ Waiver
LID #:
LOT: 4 BLOCK: _T
L:\TEMP\DST's\Forms\Street File Checklist.doc
APPUGATION & k_10ING PERMIT -
crty OF EDMONDS Building Department
Permit limit, one year
APPLICATION is hereby made for a pennit to construct. the following work, in accordance with the accom-
panying plans and specifications. Two sets are submitted herewith for approval.
n alter Off -St.
Work (;aed;n' repair ........................ ir ......................................
Parkin
g ....
..................
.
Use zone.Fire zone...........................Occupancy-----
onst. type--D
......... ..... Lot ....... ± ...... BI
Address ...... 11 e4e
Poi ..............�
Lot frontage ........................................ Arez --- --- ..0Sept1c tank_._. _o� ... ......................
Bldg. setbacks —front ............. ......... r. side.._.... .................... 1. side......_._... ........... rear ..............
y .................
0'e --
..... Tel.
Owner. 7 .......... Address ..... . .....................
Builder- -------------------------•--- ------------------ — Address.._._.....---....----...---...----___.__............ Tel. ..............................
Plansby ------------------------------------------------------------------ Address .................................. ................. Tel. No-----------------------------
..................
Remarks ---------------------------------
......................
.......................................................... I ............ ..... /4 ....................................... I ...........
The above is 3. correct statement, and I agree to comply with all applicable Codes and State laws regulating this
work.
tte.
Signed Owner/AgentAddress ......... ...... ............ ... . "'�V
'3
PERMIT for the above work is hereby approved, subject to the above conditions, and to compliance.with thei
p
proved plans and specifications, and Building Department notations thereon.
. . ............. Permit fee-
4 ................ Recd. by.,2 -,,,.(-e ...... ------ 7.
Valuation ......... —
.. ............... Date Department, By ...............%✓
NOTE —`this permit does not cover plumbing, sewer, or electrical installations, nor does it permit any work t6"be..
drme in the Right of Way areas. Driveways and wal' ways must be planned to meet the official grades of streets:
and alleys, and plans for future sidewalk development.
APPLICATION CARD No . .......... - .........
for
The City of Edmonds SIDE SEWE)t PERMff EASEMENT No. .................. ...........
OUTSIDE 0 INSIDE El REPAIRS 0
4 , d
OWNER.......'.`......T.........
..... .. . ......................... CONTRACTOR
............................................. ....... I ............ PERMIT No.
STREET
HOUSE No . .............. ............. ........ .e.. AVENUE LOT No....................................... .................. .............. BLOCK No......................................... .......................
I ........
NAMEADD ....................... ......... . ........ I . ...... ............... I ...... I .......... ........ . .. .. .. ... ................... .................. .. ...............
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Date
BACKFILL WORK ORDER ISSUED ............................................ DEPOSIT, $ .............................
SEWER WORK ORDER ISSUED ................................................
Approved:
DATE .. ... .. ............ d....... . 6 . .......... BY ....