780382.pdfBUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION Inside Heavy Lines
NAME (OR NAME OF BUSINESS)
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HONE NUMBE
.LEI'HONE NUMBER
TY LICENSE NUMBS
or Attach Four Cooie
M.r.4 El RESIDENTIALGAS
LINE
IE] NON-RESIDENTIAL ❑ SIGN
❑ ADD ❑ DEMOLISH
RETAINING
�cI WALL
ElALTER ❑ ORC FILL (�( I (E r FT)
❑ REPAIR NSP, � PoWI
o
UMBER OF STORIES NUM B R OF
DELLIENG /M ���
UNITS C 1I�/L�//
TORE OF WOR
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ABUTTING STREETS)
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i hereby acknowledge that 1 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 be employed in violation of the Labor Code of the State of Washington
relating to Workmen's Compensation Insurance,
NOTE: Permit Limit One Year(Except DEMOLITIONS and FILL
PERbIITS without conditional use permit, which shall be completed in 90
days; h10V 1N B ILDINGS shall be completed in six months,)
SIGNAT (OW OR ENT) DATE SIGNED
u-�-7�''
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marquees, etc.) will require separate permission,
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. UBC 304, 306.
I�
USE PERMIT
ZONE NUMBER
Flo
PUBLIC RIGHT OF WAY PER ORDINANCE NO.
EXISTING RIGHT OF WAY zCOO
PROPOSED RIGHT OF WAY t.'J,0/"gQ.
DEFICIENCY OF RIGHT OF WAY C.O::I
STREET/UTILITY WORK REQUIRED ❑YES
PERMIT FOR WORK IN PUBLIC R/W ❑YES WNO
UNDERGROUND WIRING REQUIRED ❑YES ®NO
CONNECTION TO SANITARY SEWER DYES AESNO
SEPTIC TANK PERMIT REQUIRED ❑YES EN NO
SEPTIC TANK PERMIT NO.
SEE MEMO DATED
REMARKS
CH
Y SIZE
SIGN
AREA
ENV.
REVIEW
ADB NO.
ALLOWED
I PROPOSED
COMPLETE
I EXEMPi'
REMARKS
VARIANCE OR CU PLANNING REVIEW BY DATE
YARDS LOT COVERAGE
FRONT SIDE REAR
FIRE ZONE TYPE OF CONSTRUCTION I CODE 1HEIGHT
SPECIAL INSPECTOR
REQUIRED
❑ YES ❑ NO
G✓'C iE
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
TOTAL AMOUNT DUE
ATTENTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
775-2525
OCCUPANCY
GROUP
OF EDMONDS, .LOCA
SHOULD BE CODED
VALUATION
LOAD
HE CITY
ES TAX
FEE
O aa�t
00
APPLICATION APPROVAL
This application is not a permit
until signed by the Building Official or
his Deputy; and fees are paid, and
receipt is acknowledged in space pro-
DIR
0r
ORIGINAL — File
PINK — Owner
YELLOW — Inspector
GOLD — Assessor
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