780560.pdfBUILDING DEPARTMENT I Applicant Fill
PERMIT APPLICATION Inside Heavy Lines
NAME (OR NAME OF BUSINESS)
AUL W , Kf49ols7P%A
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PERMIT 780560
ZONE _�C j/ NUMBER
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ADDRESS �%UJ /Q/AI
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❑YES ONO
PUBLIC RIGHT OF WAY PER ORDINANCE NO.
EXISTING RIGHT OF WAY
PROPOSED RIGHT OF WAY
DEFICIENCY OF RIGHT OF WAYS_
STREET/UTILITY WORK REQUIRED ❑YES
PERMIT FOR WORK IN PUBLIC R/W ❑YES
UNDERGROUND WIRING REQUIRED El YES
CONNECTION TO SANITARY SEWER ❑YES
SEPTIC TANK PERMIT REQUIRED ❑YES
SEPTIC TANK PERMIT NO.
SEE MEMO DATED
REMARKS
ECKED BY
SIGN AREA ENV. REVMw
ALLOWED I PROPOSED COMPLETE EXEMPT
REMARKS
VARIANCE OR CU PLANNING REVIEW BY
YARDS I /
FRONT SIDE
GAS FIRE ZONE TYPE OF CONSTRUC'
RESIDENTIAL LINE
❑ NON-RESIDENTIAL ❑ SIGN
RETAINING SPECIAL INSPECTOR AREA
❑ DEMOLISH ElWALL REQUIRED
EXCAVATE FENCE ❑ YES ❑ NO
❑ OR FILL ( X-FTI PLAN CHECKED BY I
❑ OF ED
PRE -MOVE SWIM SHOUL
C.I INSP, POOL
ARKS l
RIES NUMBER OF r!/
DWELLING f
UNITS
IK TO BE DONE
ING STRE
In •'ppplicant, on behalf of his or her spouse, heirs, assigns and
in W successors in interest, agrees to indemnify, defend and hold harmless
J
F the City of Edmonds, Washington, its officials, employees, :m
rc agents from any and all claims for damages of whatever nature,
iarising directly or indirectly from the issuance of this permit. Issu-
a ance of this permit shall not be deemed to modify, waive or reduce
J any requirement of any city ordinance nor limit in any way the
x City's ability to enforce any ordinance provision."
I hereby acknowledge that 1 have read this application; that the in-
formation given is correct; and that I am the owner, or the dully 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 Compensatioti Insurance.
NOTE: Permit Limit One Year(Except DEMOLITIONS and FILL
PERMITS without conditional use permit, which shall be completed in 90
days; h10VED-IN BUILDINGS shall be completed in sip months.)
SIGNATU E (OWNER/)OR AGENT) DATE SIGNED
79
AN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidowalks, driveways,
marquees, etc.) will require separate permission.
ATTENTION
,,..,, AO,Icrll.l'n u¢E On CGLUpy A RUILOING OR STRlfnv ,IF
— — l�lii
AL AMOUNT DUE
ATTENTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
775-2525
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N NO.
❑ FIO
El NO
El NO
❑ NO
❑NO
:HORELINE x
DATE
COVERAGE
AX
VALUATION I FEE
MR
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Y
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APPLICATION APPROVAL
This application is not a pernlit
until signed by the Building Official or
his Deputy; and fees are paid, and
receipt is acknowledged in space pro-
vid :
DIRErR'S SIGN TTUHW
q-a -7y
ORIGINAL — File YELLOW — Inspector
PINK — Owner GOLD — Assessor
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