820438.pdfIe n
USE PERMIT
CITY OF EDMONDS
ZONE NUMBER
82043iR
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CONSTRUCTION PERMIT APPLICATION
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NAME (OR NAME OF BUSINESS)
JOB
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LEGAL DE SCRII>TION CHECK ::IIDDIYISION NO
LID NO
MAILING ADDRESS
GIT TE LEPNONE NUMBER
PUBLIC RICH( OF WAY PER OFFICIAL STREET MAY
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EXISTING REQUIRED DEDICATION
PROPOSED
NAME
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED
U ADDRESS
STREEI USE PERMIT REOUIRED
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SEE ENGINEERING MEMO DAIED
---------
`CITY TELEPHONE NUMBER
SEE PIW DEPT REVIEW CHECK LIST DATED -
_... ____.. .._.. _.....
REMARKS
NAME
ADDRESS
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METER SIZE BUILDING SUPPLY S1ZE
FIXTURE UNITS
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¢ CITY TELEPHONE NUMBER
2l
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REMARKS
D STATE LICENSE NUMBER CITY LICENSE NUMBER
SIGN AREA ENV REVIEW AO.
ALLOWED PROPOSED COMPLETE
EXEMPT
Legal Description of Property • Include all easements
(show below or attach four copies)
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VARIANCE OR Cu PLANNING REVIEW BY DATE
YARDS /L
N x
LOT COVERAGE
FRONT SIDE
REAR
NEW I� RESIDENTIAL
U PLUMBING
❑ ❑
❑
ADDIALTER
NON.RESIDENTIAL
MECHANICAL
❑ ❑
WALL
❑ SIGN
REPAIR
❑ ❑
RETAINING
EXCAVATE
FENCE
❑
CHECKED BY I TYPE OF CONSTRUCTION CODE HEIGHT
1919
DEMOLISH
OR FILL
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❑PRE
-MOVE INSP.I
❑ SWIM
SPECIAL INSPECTOR AREA
OCCUPANCY OCCUPANT
COMPLIANCE INSP.
POOL
gE0U1RE0
GROUP t-j �2 LOAD
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❑ SIDE SEWER ❑
WATER LINE
❑
YES NO
REMARKS
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1N� ST ALL- ipoL M
h) 5 SPGjt•s d-
❑ ❑
❑
NUMBER OF STORIES
NUMBEROF
,-k" 6, G
�;TATe COeS
DWELLING
I
UNITSP9-0
PLANT
,RESS 1tJ`7�ELTIo S (Z6G2ti
MATURE OF WORK TO BE DONE (ATTACH PLOT
VALUATION
IEEE,
FEE
PLAN CHECK FEE
F`l C ���ro
BUILDING
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MECHANICAL
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This Permit covers work to be done on private property ONLY. GRADINGIFILL
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission.
Permit Application: 180 Days
Permit Limit: 1 Year- Provided Work is Started Within 180 Days
.'Applicant, on behalf of his or her spouse, heirs, assigns and
successors In Interest, agrees to Indemnify, defend and hold
harmless the City of Edmonds, Washington, its officials,
m employees, and agents from any and all claims for damages of
a whatever nature, arising directly or indirectly from the issuance
of this permit. Issuance of this permit shall not be deemed to
° modify, waive or reduce any requirement of any city ordinance
°x nor limit in any way the City's ability to enforce any ordinance TOTAL AMOUNT DUE
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provision."
1 hereby acknowledge that I have read this application; that the ATTENTION
APPLICATION APPROVAL
Information given is correct; and that I am the owner, or the duly
authorized agent of the owner. I agree to comply with city and THIS PERMIT
This application is not a permit until
state laws regulating construction; and In doing the work authoriz. AUTHORIZES
ed thereby, no person will be employed In violation of the Labor ONLY THE
signed b the Building Official or his
9 Y 9
Code of the State of Washington relating to Workmen's Compensa. WORK NOTED
Deputy; and fees are paid, and receipt is
tI n Insurance. INSPECTION
acknowledged in space provided.
SIGNATU E Ij
�O/V�E l yRI OR ADENTI DATE SIGNED DEPARTMENT
i G I�
OFFICIAL'S SIGNATURE
'r '_ CITY OF
THIS SITE IS LOCATED IN THE CITY EDMONDS
ATTENTION OF EDMONDS. OULD BE CODED 31,04 ALES TAX 7752525
Dar[
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
ORIGINAL — File YELLOW — Inspector
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. UBC
CHAPTER 3.
102 lb
PINK — Owner GOLD — Assessor
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Water service
HEATING SYSTEM
FRAMING
WALLBOARD
FINAL
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