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DEPARTMENT ApplicantFill
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PERMIT APPLICATION Inside
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NAME 11111 NAME OF BUSINESS) 66
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CITY TELEPHONE NUMBER
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EXISTING REET R/W ............FT. DEFICIENCY THIS PROPERTY
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NAME
COMP. PLAN ST. R/W ............FT. ............FT,
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`� A ��� Driveway to those
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MLTt:fi B12E BERM SIZE CLEARANCE CHEC C D BY
STATE LICENSE NUMBER CITY LICENSE NUMBEK
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REMAt tl UI
Legal Description of Property (Show Below or Attach Four Copies) / �rQ O
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REMARKS
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FIRE ZONE TYPE OF CONBTR CTION STR T Ie1PROVED
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SPECIAL INSPECTO EQUIRED OCCUPANCY GROUP
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GAS Q YES �•f0 ' IT -1
RESIDENTIAL LINE
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NEW THIS SITE IS LOCATED IN THE CITY
NON-RESIDENTIAL slcN �h OF EDMONDS. LOCAL SALES TAX
ADDARKS/ SHOULD BE CODED 31.04.
❑ yALL NING
DEMOLISH
El ALTER EXCAVATE FENCE All ��,�dc� /v .J P63"'�/ alSC 1?;d
OR FILL (..........z .......... Fl.)�t-
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MOVE O POOL d (✓r/J - t�"� /� fTJt/ sib �NlPcrcr?a
REPAIR ❑ INSP
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NUMBER OF STORIES N UMBER OF
/ DWELLING
UNITS
NATURE OF WORK TO BE DONE
Valuation
Fee Receipt No.
Plan Cheek Nn
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�(���� BUILDING -S �ii/� ]
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PROPOSED UBE \
PLUMBING
PLOT PLAN (Indicate Building setbacks, abutting streets) HEAT A GAS LINE �% Qd•I
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FENCE
SIGN
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RETAINING WALL
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SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL --
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1 hereby acknowledge that I have read this apDllcnllon; that the In- TOTAAMOUNT DUE J
formatlan given Is correct; and that I am the owner, or the duly author-
Ixed "c" of the owner. I agree to comply with city and state laws regu• ATTENTION APPLICATION APPROVAL
Ialing conetrueu b; and In dolvg the work nutharl:ad thereby, no person
Will be employed In violation of the Labor Code of the State of Washington THIS PERMIT This application Is not a permit until
relating to Workmen's Compensation Insurance. ABTHORiZEB signed by the Building Official or his Dep -
ONLY TILE
NOTE: Permit Limit One Year (Ezcapt DEefOLiT[ONd which waRH NOTED uty; and fees are paid, and receipt is ac -
shell be completed in Neely day.; MOVED -IN BUILDINGS shall be com- knowledged In space provided.
pleted In six months.)
SIGNATURE
(OWNER Oft AGENT) DATE SIGNED INSPECTION 3R C7 'B fa TUBE
-
DEPARTMENT
o fJC�
CITY OF
EDMONDS 'DATE
NOTE: Applicant Subject to Plan Check Fee --"z I/-
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775-2525 C5
This 1'ermll r cork to bo done on prlrnle property ONLY.
Any coast Ian¢n the public domain (curbs, sldewalit.. driveways,
FILE
mnryue... etc,) will require .eparote permission.
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BUILDING DEPARTMENT Appilriant F111 NUMBER
PERMIT APPLILAIIUM I Inside Heavy Lines
NAME (OR NAME OF BUSINESS)
C
AILING ADDRESS
ADDRESS
CITY I TELEPHONE NUMBER
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NAME
kUj ADDRESS
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ADDRESS
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EgT COVERAGES
ACTUAL
LOT COVERAGE J�`
PERMIRBIBLE HEIGHT
PROPOSED IIE1IOHT
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TELEPHONE NUFBER
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ACTUAL LOT AREA
TOTAL: BLDG./ AREA
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REQUIRED AR H PROP08ED YARDS
FRONT HIDE
REAR FRONT 131DE REAR
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1!5 ,'4 1 � / /;)� (,� o
LEGA I. LUT
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VAHIANCE OR CONDITIONAL USE
CZYE9 NO
PERMIT NUMBER
PLA NjNLN0 DEFT.,A—ROVAL. ATE:
CITY
TELEPHONE NUFBER
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STREET R/W/ ' 0
EXISTING STREET R/W ............ FT. DEFICIENCY THIS PROPERTY
NAME
_ADDRESS,
COMP. PLAN ST. R/W ...FT .......... FT.
REMARKS
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CITY
TELEPHONE NUMBER
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METER SIZE SERVICE SIZE CLEARANCE
CHECKED BY
STATE LICENSE NUMBER
LICENSE NUMBER --
[CITY
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REMARKS
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Legal Description at Property (an— Below or Attach Four Copies)
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TYPE CONNECTION VEMIED�Byl
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PERPST PER I NUMBER
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TYPE OF CONSTR
FIRE ZONE OTRIMT '111411ROVED
YES NO
SPECIAL INSPECTOR.REQUIRED OCCUPANCY GROUP
RESIDENTIAL
E] GA,,S,
0 YES NO
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NEW
AA. CHECKED BY
THIS SITE IS LOCATED IN THE CITY
NON-RESIDENTIAL SIGN
0
OFEDM ONDS, LOCAL SALES TAX
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SHOULD DED 31.04.
ADD RETAINING
WALL
REMAI—S
❑ DEMOLISH
ALTER EXCAVATE FENCE
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❑ OR FILL❑ (........_...........Fl.)
. ........ . ..
REPAIR ❑ PRE -MOVE
POOL OOL
NUMBER —STORIES 111113011 Oil
DWELLING
UNITS
NATURE OF WORE. TO BE DONE
Valuation
Fee Receipt N o.
rhut Check N. .....................
BUILDING
4�1
PLUMBING
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PLOT PLAN (Indlcato streets)
HEAT & GAS LINE
FENCE
SIGN
RETAINING WALL
N,
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
I hereby acknowledge that I have read this application; that the In.
TOTAL AMOUNT DUE
formation given Is correct; and that I sun the owner, or the duty author-
Ized agent ofthe owner. I agree to cOmPlY with city and state laws regu-
toting construction; and In doing the work authorized thereby, no person
ATTENTION APPLICATION APPROVAL
will be employed In violation of the Labor Code of the State of Washkpgton
to Workmen'.
THIS PERMIT This application Is not a permit until
relating Compensation Insursubals.
NOTE: Permit Limit One Year DEMOLITIONS
AUTHORIZES
ONLY TH signed by the Building Official or his Dep -
(E—Pt which
WORK NOTED uty; and fees are paid, and receipt is ac -
shall be tomPleted In ninety days; MOVED -IN BUILDINGS shall be com.
knowledged in space
pleted-In mix months.)
provided.
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SIGNATURE (OWNER OR OENTDATE TF SIGNED
INSPECTION —DIRECTOR'S SIGNATURE J 1/
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DEPARTMENT
CITY OF L
EDMONDS DATE
NOTE: Applicant Subject to Plan Cbeck Fee
This Permit Covers work to be done on private Property ONLY.
775-2525
Any construction an the public domain (curbs, sidewalks, drive..,.,
marquees, etc.) will require separate permilulloa.
INSPECTOR
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