100023353 Variance Request.pdfOV E b'110
Al r 41 DEVELOPMENT SERVICES
WORK HOURS VARIANCE REQUEST FORM
121 51h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 0 Fax 425.771.0221
PROJECT NAME:
PERMIT(S) #:
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PROJECT ADDRESS:
APPLICANT:
Phone:
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i:�,5-703--Y 9,�z as 51z.3�Z
Address (Street, City, State, Zip):
E-Mail:
/
PROPERTY OWNER:
Phone:
Address (Street, City, State, Zip):
E-Mail:
CONTACT PERSON: (This person must be available at all times that
Phone:
extended work is being performed)
Address (Street, City, State, Zip):
E-Mail:
CONTRACTOR:
Phone:
Address (Street, City, State, Zip):
E-Mail:
DATES AND TIME OF EXTENDED WORKTIME REQUESTED:
WA State Contractor License #/Exp. Date:
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City of Edmonds Business License #/Exp. Date:
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DETAIL THE SCOPE OF WORK TO BE PERFORMED DURING THE REQUESTED TIMES:
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A RATIONALE FOR THE PROPOSAL SHALL BE SUBMITTED IN ADDITION TO THIS FORM. PLEASE REFER TO THE WORK
HOURS VARIANCE REQUEST HANDOUT WHICH ASKS FOR AN EXPLANATION OF HOW THE ACTIVITIES WILL COMPLY WITH
THE REQUIREMENTS OF THE VARIANCE ORDINANCE.
Print Name:
Signature: Date:
FORM B V:IDESKT0P11Vork Hours Variance Form B 2017 docx Updated: 09/25/2017