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BUILDING DEPARTMENT
Applicant Fill
PERMIT APPLICATION
Inside Heavy Lines
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ADDnESe
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7'
ACTUAL ry
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LOT C VERASIBLE
LOT COVERAGE
LOT COVEStAGE
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PERMISSIBLE HEIGHT
Pilo DIED HEIGHT
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AREA
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CITY TELEPHONE NUMBER
ACTUAL LOT AREA
TOTAL BLDG.
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REOUIfl ED YARDS
PROPOSED YARDS a{
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FRONT 81—DE
REAR FRONT SIDE REAR
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LEGAL LOTARIANCE OR CONDITIONAL USE
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ADDRESS
[3 YES NO PERMIT NUMBER
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PLANNING DEPT. APPROVAL DATE:
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CITY TELEPHONE
NUMBER
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STREET
EXISTING STREET R/W ............FT.
DEFICIENCY THIS PROPERTY
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NAME
COMP. PLAN ST. R/W ............FT.
............FT.
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REMARKS
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ADDRESS
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CITY TELEPRONE
NUMBER
(CHECKED
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METER SIZE
SERVICE SIZE
CLEARANCE
CHECKED BY
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STATE LICENSE NUMBER CITY
LICENSE NUMBER
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REMARKS
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Legal Description of Property (Show Below or Attach Four Copies)
TYPE CONNECTION
VERIFIED BY
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PERC. TEST
PERMIT NUMBER
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REMARKS
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FIRE ZONE TYPE OF CONSTRUCTION STREET IMPROVED
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D YES 13 NO
SPECIAL INSPECTOR REQUIRED
OCCUPANCY GROUP
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❑RESIDENTIAL
OAS
FJLINEPLAN
❑ YES ❑ NO
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NEW
CHECKED BY
THIS SITE IS LOCATED IN THE CITY
SALES TAX
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❑ NON-RESIDENTIAL
❑ BION
OF EDMONDS. LOCAL
SHOULD BE CODED 31.04.
ADD
REMARKS
❑RETAINING
DEMOLISH WAIT
-section 12.14.040
EXCAVATE FENCE
ALTER ❑ OR FILL
Fence requirements
attached.
❑PRE -MOVE SWIM
REPAIR E](NBP. �
POOL
If
NUMBER OF STORIES NUMBER OF
DWELLING
UNITS
NATURE OF WORK TO BE DONE
Valuatlon
Fee Receipt N.,
Plan Check No .....................
BUILDING
PROPOSED UBE
PLUMBING
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PLOT PLAN (Indicate Building setbacks, abutting streets)
HEAT k GAS LINEo
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PENCE
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SIGN
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RETAINING WALL
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SWIMMING POOL
DELIOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
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I herehy a,kn.wi.1,. that I have read this application; that the 1n-
o� t
formation given le correct; and that I am the owner, or the duly author-
Ized agent of the owns,. I agree to comply with city and elate laws regu.
ATTENTION
APPLICATION APPROVAL
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lating construction; and In doing the work authorized thereby, no person
will be employed In violation of the Labor Code of the Stale of Washington
THIS PERMIT
This application is not a permit until
relating to workmen's Compensation Insurance.
AUTHORIZES
signed by the Building Official or his Dep -
NOTE: Permit Limit One Year (Except DEMOLITIONS which
ONLY THE
WORK NOTED
uty; and fees are paid, and receipt is ac
completed In ninety d ;OYXD-IN BUILDINGS Shall be com.
,hall beaf
knowledged in space provided.
pitted In six month..)
SIGNATU (OWNR GENT)
DATE 816NE
INSPECTION
DIR CTOR'e tnGNATU
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DEPARTMENT
f ,�✓Isis.: �/�r(. %��
CITY OF
ED11fOND8
DATE
----
heck Plee
OTE: Applicant Subject to Plan
775-2525
G.L
This Permit r cera work to be done on private property ONLY.
Any construct,.. on the public domain (curbs,sldew•niks, drhron,"..
FILE
ed -Q. es. Ste.) will Mpmre separate permission.
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