840163.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
NAME IOR NAME OF BUSINESS)
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,,,I `---J'EEE���� NEW L`1 RESIDENTIAL
U ADDIALTER NONRESIDENTIAL
REPAIR RETAINING WALL
EXCAVATE
DEMOLISH OR FILL
0PREMOVE
1 COMPLIANCE
SIDE SEWER CI WATER LINE
NUMBER OF STORIES �NUMRFROI
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NATURE OF WORK TO BE ONE (ATTACH
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S- I2- NUMBER 840163
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
EXISTING__ ,_._ REQUIRED DEDICATION-__
PROPOSED,—.,—,.
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED
STREET USEPERMIT REQUIRED'.
SEE ENGINEERING MEMO DATED.... .... _.. N.._ _. _.... -. _.. .
SEE PIW DEPT. REVIEW CHECK LIST DATED__
I METER SIZE BUILDING :'.UPPLY SIZE FIXTURE UNITS
TE ECgNE NUMBER Ou REMARKS
LICENSE NUMBER &X►5TI hl V LjG-IZV I C_e
SIGN AREA
ENV. REVIEW
ADB
ALLOWED
asementS
PROPOSED
COMPLETE
MP
I
SHORE
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VARIANCE OR CU _ PLANNING REVIEW BY , DATE
YARDS SIDE
D �S- R LOT CCOV R o
FRONT
I'I PLUMBING
❑
MECHANICAL
SIGN
FENCE
CHECKED BY
I— X _FT)
❑SWIM
SPECIAL INS
POOL
REQUIRE.
❑
1 : YES
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IEA OCCUPANCY OCCUPANT
GROUP V �� LOAD
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VALUATION r-EE
PLAil G�IFCI FE;. n1 O
BUILDING 17,0 OUO
PLUMBING
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O 1 ' MECHANICAL
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This Permit covers work to be done on
private property ONLY, cnaolNcl L
Any construction on the public domin (curbs, sidewalks,
driveways, marquees, etc.) will requir separate permission.
Permit Application: 180 Days
Permit Limit: I Year • Provided Work is Sl rled Within 180 Days
"Applicant, on behalf of his or her spouse, heirs, assigns and
in interest, agrees to Indemnify, defend and hold
wsuccessors
harmless the City of Edmonds, Washington,
Its officials,
employees, and agents from any and a
1 claims for damages of
whatever nature, arising directly or Indirectly
from the Issuance
of this permit. Issuance of this permit
shall not be deemed to
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modify, waive or reduce any requirement
i nor limit in an way the City's ability to
y y y
of any city ordinance
enforce an ordinance
y TOTAL AMOUNT DUE
C� 3�
I FjQ 2Z
provision."
I hereby acknowledge that I have read
This application; that the
Information given is correct; and that I aln
the owner, or the duly
ATTENTION
APPLICATION APPROVAL
authorized agent of the owner. I agree o comply with city and
1
state laws regulating construction; and in doing the work authoriz-
THIS PERMIT
AUTHORIZES
This application Is not a permit until
ad thereby, no person will be employed In violation of the Labor
ONLY THE
signed by the Building Official or his
Code of the State of Washington relating to Workmen's Compensa•
WORK NOTED
Deputy; and fees are paid, and receipt is
acknowledged in space provided.
tion Insurance.
INSPECTION
SIGNATURE IOWNER OR AGENT)
PATE SIGNED
DEPARTMENT
OF CITY
OFFICIAL'(�-� SIGNATURE
vim,
EDMONDS
ATTENTION
t 3202
.Ak. 2198�
DATE
IT IS UNLAWFUL TO USE OR OCCUPY q' BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEENIMADE AND APPROVAL OR
,.-J�RIGINAL — File YELLOW — inspector
A CERTIFICATE OF OCCUPANCY HAS
BEEN GRANTED. UBC
CHAPTER 3.
i
PINK — Owner GOLD — Assessor
W2 78
APR 21984
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