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BUILDING DEPARTMENT
PERMIT APPLICATION
POSTED
Applicant Fill
Inside Heavy Linea JOB
ON KROLL ill" NO.:
PERMIT
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ADDRESSr
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BIDE
YARD SETBACK
STREET SETBACK
REAR YARD SETBACK
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VACANT VACANT SITE
13 YES ❑ NO
CIT TELEPHONE NUMBER
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HEIGHT
HUILDINO AREA
VARIANCE NUMBER
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NAME
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PLAN APPROVED
ADDRESS
STREET
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EXISTING STREET R/W ............FT. DEFICIENCY THIS PROPERTY
CITY
TELEPHONE NUMBER
COMP. PLAN ST. R/W ............FT. ............FT.
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REMARKS
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NAME
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CHECKED BY:
CITY
I TELEPHONE NUMBER
METER SIZE I SERVICE SIZE I CLEARANCE
I CHECKED BY
STATE LICENSE NUMBER
CITY LICENSE NUMBER
REMARKS
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Legal Description of Property (Show Below or Attach Four Copies)
-
TYPE CONNECTION
BY
IVERIFIED
PERO. TEST
PERMIT NUMBER
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REMARKS
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FIRE ZONE. I TYPE OF CONSTRUCTION I STREET IMPROVED
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NEW
RESIDENTIAL
❑
GAS
LINE
NON-RESIDENTIAL
"SIGN
ADD
PXTAINING
ALL
ElQ
DEMOLISH
E
ALTER
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OROAVATFILL
('.E..NCE
Ft.)
REPAIR
❑
PRE -MOVE
INSP.
..=..........
swim
POOL
(UMBER OF STORIES
NUMBER OF
DWELLING
UNITS
I hereby acknowledge that I have read this application; that the in-
formation given Is correct; and that I am the owner, or the duly author-
ized agent of the owner. I agree to comply with city and state laws regu-
lating construction; and in doing the work authorized thereby, no person
will he employed In violation of the Labor Code of the State of Washington
relating to Workmen's Compensation Insurance.
NOTE: Permit Limit 0 Yeer (Ezcept DEMOLITIONS which
shall be cympigt�(1; In ningty yg(MOVED-IN BUILDINGS shall be com-
pleted. six e.) � /
NOTE: Applicant Subject to Plan Check Fee
This Permit coven work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marquees, etc.) will require separate permission.
YES
CS ❑ NO
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Valuation Fee Receipt
Plan Check No .....................
BUILDING
PLUMBING
HEAT d: GAS LINE
FENCE
SIGN �� . �) 4n
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
ATTENTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PR e-1107
No.
1 %. 2c 1 4/o 6
APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or his Dep-
uty; and fees are paid, and receipt is ac-
knowledged in apace provided.
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APPLICATI �. V & WORK PERMIT
Application No.
CITY OF EDMONDS Building Department Permit Limit, One Year
APPLICATION is hereby made for a permit to construct the following work, in accordance with the accompanying plans '
k�j`t and specifications: 1
4. WORM — Ne Addn........:.f4./"r"............................................./................ round Area ................................... No. Stories............
1
Plans Submitted vZConst. Type ................................ g
. ..... . ......
LOCATION — Address ../,.// . v .................... Use Zone .. —/... Fire Zone ....................
i
RecordedLot. ................... Block.................... Add'n............................... .......................................... .............. Sewerage ....................................
M
Lot Area ....................................... Width............................ Min. Bldg. Setbacks, Front and Rear ............................... Sides..............................
Address...,lf..(... S.'1�.. a ................. Phon/�.(�..-
Plansby........,if��.C�IQ.�J%1<� 1.............................................. Address ........................................................................ Phone ................................
S�GN� b !! �l �� T�-� ...................... Address... J Sfd. .... ...AP', lc.......... Phone'/... d,,,: .;P 2—.
Plbg. by .............................. _............................................................ Address ........................................................................ Phone ................................
Heatingby........................................................................................ Address ........................................................................ Phone ................................
Elect. by............................................................................................ Address ........................................................................ Phone ................................
Remarks
The above is a correct statement and I agree to comply with all applicable Codes and State Laws regulating the work.
Signed: -OvAw/Agent .��'J.:i/ L Address ................................................. ...........................
PERMIT for the above work is hereby approved, subject to the above conditions, and to compliance with the approved plans
and specifications and Building Department notations thereon.
VALUATION PERMIT FEES
$......r...d.. Bldg. ....$........................................
Plbg. ....$........................................
APPROVED: �j Heat ....$........................................
Date............../......�1�............................. Elect. ....$ ........................................
BUILDING DEPARTMENT Others ... $........ �!, C9-U.........
....... .................. TOTAL FEE $......... �J� : .........
NOTES: No work requiring Building Department or City Engineer's inspection shall be covered before inspection and approval.
Twenty-four (24) hour notice requested. Contact the City Engineer prior to construction of all site utilities, such as
curbs, paving, driveways, sewer, water and street connections.