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Owner
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Job Address � ����° � ��, � b
Type of Inspection DOC Wlftfi
❑ WORK 6ESCR4hD
❑ APPROVED PLAN N
CORRECTIONS LIS 1
AND/OR T1 IE, NEXT
❑ RECALL FOR INS:;'I
R1 d IN S SECTION 1-1- I
X STOP WORK -UNTIL
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AND/OR OWNER
REQUIRED IX ENFORCEMENT VIOLATION
ritNumber (2
Contact
BELOW HAS BEEN INSPECTED AND APPROVED.
�NI)JOB CARD MUST BE AVAILABLE TO INSPECTOR ON SITE.
P31) BELOW MUST BE MADE BEFORE WORK CAN BE APPROVED
PIA$E OF WORK IS STARTED.
UTHORIIZED TO CONTINUE BY CITY INSPECTOR.
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THE ACTIONS OR CORRECTIONS INDICATED ABOVE ARE REQUIRED TO BE CORRECTED BY
(DATE) ......�.............
OR PENALTIES MAY BE APPLIED. FOR INSPECTION CALL 425-771-0220
I Building ❑ Planning ❑ Engineering ❑ Fire ❑ Public Works
Inspector �� "� ." � Date At"5Zi,
THIS NOTICE TO REMAIN ON SITE
White: Permit File Buff: Applicant
tit 1
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
1 121 5th Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 2 Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street%Suite #,
Parcel #:
ision/Lot #: Project Valuation: $
APPLICANT: Phone: Fax:
I Ge__CnE,�tll� —,2Z,,)C, ZA
Address (Street, City, State,
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P E Mail Address:
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AA
PROPERTY O ER: eT ° Phone. Fax:
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Address (Street, City, Zip): E-Mail Address:
rLENDINOAGENCY: Phone: Fax:
(Street, City, State, Zip):
1s rmnu . *
Address (Street, City, State, Zip):
E-Mail Address:
P . e: � Fax:.
E-Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
DETAIL SCOPE OF WORK:
_
PROPOSED NEW
Basement:
lst Floor:
2 na Floor:
Retainina Wall: ❑ Yes 1-1 No
11
t
UARE FOOTAGE FOR THIS PROJECT:
ft. Select Basement T e: ❑ Finished ❑ Unfinished
ft. Garage/Carport:
ft. Deck/Patio: ft.
•.•
Other: sqg ft
I declare under penalty of perjury laws that the information I have provided on this form/application is true, correct and
complete, and that I am the property owner or duly authorized agent of the property owner to submit a permit application to
ds
City f �
Owner ❑ Agent/Other (specify): the � o Edmonds.
Print Name: 2 t,:��l,:''
Signature:• ._ Date:
FORMA CAIWIding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A.doc Updated: 10/2011