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` CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
NAME (OR NAME OF BUSINESS)
k�r'dA/ _R.%Z.
IDDRESS
0?l o 3,
;ITY
VXA /7ZE
DAME
ADDRESS
CITY
STATE LICENSE
/C (/Ew ;DR.
VG1•
rELEPHONE NUMBER
��1,;;1 , '9616
ust PERMIT 830308
ZONE �L � � �J NUMBER
JOB % O 1 10 D VD
ADDRESS
I crM nFRC:RIPTInN r.HFrKI SUBDIVISION NO. ILID NO.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP,
EXISTING REQUIRED DEDICATION
PROPOSED
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED ❑
STREET USE PERMIT REQUIRED El
SEE ENGINEERING MEMO DATED
SEE PIW DEPT. REVIEW CHECK LIST DATED �• /�
REMM" A �s2i//11i%/� ✓VY � ��/ _
� 100
METER SIZE BUILDING SUPPLY SIZE FIXTURE UNITS
0ourcoples)
NE NUMBER
REMARKS
ENSE NUMBER % G 45
SIGN AREA ENV. REVIEW ADB NO.
ALLOWED PROPOSED COMPLETE EXEMPT
,]::
ments f SHORELINE
1(2��_/�N;\'VARIANCE OR CUPLAN NG REVIEW Y DATE
a-7YARD�S//��LOT COVERAGE
�� F 'S FRONT ID SIDE .�1J�r REAR
❑ NN yy LJ RESIDENTIAL U PLUMBING
LJ ADDIALTER ❑ NON-RESIDENTIAL El MECHANICAL
❑ REPAIR ❑ RETAINING WALL ❑ SIGN
EXCAV❑ DEMOLISH ❑ OR FILL
❑ `ENCE
x _FT)
n PRE -MOVE INSP.I n SWIM
❑ SIDE SEWER ❑ WATER LINE ❑
❑ ❑ ❑
NUMBER OF STORIES NUMBER OF
OF WORK TO BE
AsmT
V/N
DWELLING
UNITS
E (ATTACH PLOT PLAN)
F /19A/1V
-ll
SPECIALINSPEGTOK
REQUIRED
IIYES I'NO
PLAN CHECK FEE
/kMlly BUILDING
C'LOOROS PLUMBING 5
MECHANICAL
OF CONSTRUGIIUN wvo n"Iv"
43 2 1 °119 .5'M
T
REA OCCUPANCY OCCUPANT
GROUP pZ o LOAD
It�SU�. PSYL 1980 d�?�tm Cc
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 F L Al l IMeV1%
Permit Limit: I Year- Provided Work is Started Within 180 Days
"Applicant, on behalf of his or her spouse, heirs, assigns and
cn successors in Interest, agrees to indemnify, defend and hold
W harmless the City of Edmonds, Washington, its officials,
2 employees, and agents from any and all claims for damages of
zwhatever nature, arising directly or indirectly from the Issuance
of this permits Issuance of this permit shall not be deemed to
0
modify,.waive or reduce any requirement of any city ordinance
° nor limit in any way the City's ability to enforce any ordinance TOTAL AMOUNT DUE
provision."
I hereby acknowledge that I have read this application; that the ATTENTION
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
state laws regulating construction; and in doing the work authoriz- AUTHORIZES
ed thereby, no person will be employed In violation of the Labor WRK OONLY TH NOTED
Code of the State of Washington relating to Workmen's Compensa•
tion Insurance, INSPECTION
SIIG�+ATURE,(OWNER OR t�G��T) DATE S"NJD DEPARTMENT
U�Ct/J O� •��J 9 CITY OF
THIS SITE IS LOCATED IN THE CITY
EDMONDS
OF EDMONDS. LOCAL SALES TAX 775.2525
ATTENTION SHOULD BE CODED 31.04,
IT IS
UNTIL ALFINAL INSPECTION AWFUL TO USE OR HOAS BEEN MADE IAND APPROVALUO(m 2 21983
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. UB'C
CHAPTER 3.
102.78
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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 provided.
OFFICIA 'S SIGNATURE
Ljic�L40 &L M �
DATE
ORIGINAL — File YELLOW — Inspector
PINK — Owner GOLD — Assessor
Kergon Pnnliny • EtImonds Y!A • 7759494
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INSPECTIONS
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.. III—— _»..... Date Passed:;_:..._ . __ . ;r,
ECORp OF INSP ,
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.�FOUNDATIO
House `
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PLUMBING 1
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