790076.pdfI
BUILDING DEPARTMENT Applicant Fill ZONE S..,�NUMBER
PERMIT APPLICATION Inside Heavy Lines JOB
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NAME (OR NAME OF BUSINESS) ADDRESS `
L I R� L7 LEGAL LOT PLAT N
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or8si5- O1 /%PJG ��� " r� PUBLIC RIGHT OF WAY PER ORDINANCE NO.
CITY TELEPHONE NUMBER
FQ, / t� � r� � EXISTING RIGHT OF WAY
.ilJl PROPOSED RIGHT OF WAY
NAME
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Legal Description of Property (Show Bel
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790076
BDIVISION NO.
STREET/UTILITY WORK REQUIRED
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YES
PERMIT FOR WORK IN PUBLIC R/W
DYES
UNDERGROUND WIRING REQUIRED
❑YES
'ELEPHONE
NUMBER
CONNECTION TO SANITARY SEWER
❑YES
DYES
SEPTIC TANK PERMIT REQUIRED
SEPTIC TANK PERMIT NO.
SEE MEMO DATED L 1
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REMARKS
TELEPHONE
NUMBER
775-�7�0
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SIGN AREA ENV. REVIEW
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•' �O \ REMARKS
VARIANCE RR CU
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PLANNING REVIEW BY
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❑ NEW 1/Y RESIDENTIAL LINE FIRE ZONE TYPE OF "CO(N,tSTRUCTION CODE''')r- HEIGHT
❑ NON-RESIDENTIAL ❑ SIGN 3 �L" v" 11 / to 30IM
® ADD SPECIAL INSPECTOR AREA OCCUPANCY OCCUPAN'
El RETAINING GROUP IZ �� LOAD
DEMOLISH ❑Wp.tt REQUIRED
❑ �� Ss4
❑ ALTER EXCAVATE FENCE YES NO
OR FILL ❑ ( X_FT) PLAN CHECKED BY THIS SITE IS Lot
OF EDMONDS. I
❑ REPAIR ❑ PRE -MOVE OSWIM I-i4- SHOULD BE COI
INSP. POOL
REMARKS
Z NUMBER OF STORIES NUMBER OF
O ONE DWELLING
F UNITS
a NATURE OF WORK TO BE DONE
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PLOT PLAN INDICATE BUILDING SETBACKS.
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In "Applicant, on behalf of his or her spouse, heirs, assigns and
W successors in interest, agrees to indemnify, defend and hold harmless
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f the City of Edmonds, Washington, its officials, employees, and
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agents from any and all claims for damages of whatever nature,
X arising 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
i City's ability to enforce any ordinance provision."
I hereby acknowledge that I have read this application; that the in-
formation given is correct; and that 1 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
PERMITS without conditional use permit, which shall be completed in 90
days; MOVED -IN BUILDINGS shall be completed in six months.)
SIGNATURE (OWNER OR AGENT] DATE SIGNED
BUILDING
PLUMBING
MECHANICAL
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
This Permit covers work to be done on private property OWLY.
Any construction on the public. domain (curbs, sidewalks, driveways,
marquees, etc.) will require separate permission.
ATTENTION
Jr IC Iwl AP:F u. TD USL OF. OCLIJPY .A BUILDING OR STRUCTURE
AMOUNT DUE
ATTENTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
775-2525
3
FEE
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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-
vided.
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