840254.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
NAME IOR NAME OF BUSINESS)
MAILING DDIIESS •�
city r ;• TELEPHO(JE NUMBER
NAME
I LI M BE
NAME
CITY ITELEP�ONE NU
STATE LICENSE NUMBER i CITY LICENSE NUMBER
Legal Description of Property - include all easements
(show below or attach four copies)
❑ NEW 1 ❑ RESIDENTIAL ❑ PLUMBING
❑I
ADD'ALTER NONRESIDENTIAL MECHANICAL
❑ REPAIR ❑ RETAINING WALL ❑ SIGN
El
OR FILL
❑ FENCE
DEMOLISH EX FLL i.-.__. ._:• Fir
7-1 FREdAOVE INSP.SWIM
❑ SIDE SEWER ❑ WATER LINE ❑
t4w,IBEv OF STORIES NUTARFROP
U41'C LLI Nh
uMIJ
NATURE OF L^.ORr: '_ PE ;O'IE IAiTAC" PL,OTPLArri
1
It
USE PERMIT}
ZONE NUMBER �� 04
JOB fit 11
:. i r • f . ,:
ADDRESS 1 D P I I
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LEGAL DESCRIPTION CHECK SUBDIVISION NO. LID NO. I '
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1
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP, (I
EXISTING__..- _.... RECUIRED DEDICATION_
PROPOSED._
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED I -
STREET USE PERMIT REQUIRED
SEE ENGINEERING tAErdO DATED.._
SEE PIW' DEPT. RFVI E:! CHECK LST DAtED.....
REMARKS t. � IX -
SIG': AREA
ALLOWED I PRO PO56D
VARIANCE OR CU
YARDS
FRONT SIOE
ENV REVIEW
C•04!PLETE EXEMPT
+•
'LANNING REVIEW BY
CHECKED BY IT't PE OF CONSTRUCTI
_INE N
DATE
LOT COVERAGE.
I `.A 1
SPECIAL I'JSPEC TOP JI UCCUPANCY
REQUIRED GROUP
YES r'JO
Rer.+ARKs
VALLIATiON
• 6L9 t.
&. Pw IE JG
r.r Erg^.tiNlt. iL
This Permit Covers tvotk to be done on private property ONLY. GRA::;',G F ...
Any ccns;rDCt:on a^ the public domain (cubs. sidev:alks.
dnvev:ays, margaa s. etc.) will require separate permission.
Perrnit .Aoalicanc , ? Days --
Perna Limit t Year ?rcrided 14'ork is Started'v'rit?in too Days
on bchal' Of his or her spouse,. heirs. asslgnS and
rressers in interest. acrees to Indernniiv. defend and holy"
haeTless the City of Edmonds. 'AVashington. its officials
employees. and avert: frorn am• and all claims for damages of
';:hateter nature. arising dirCCth, Or indlreCili'Jm the IssUarL'B
of this p '!T?!l. ISSUaIce ..r this . err lit snail not deemed t0
modlff.t'.alV 0 reauce nr !BC.liremen. v ani,' ordinance
nor 1 IT o In an: .• tic C t':'s nn1',tS to 4orce an; Ora lna n Ce
prD'.ISiQn TOTAL AMOUNT DUE
hereb,v ackne r leoce That I ha, e cad th!, anplication' ttheat th
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HEIGHT
OCCUPANT
LOAD
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FEE
information given is c rrect and that I am the owner. or Me duly ATTENTION APPLICATION APPROVAL
authorized acent of the owner. I agree tc cc•mpiy with city ano
slate laws regulating cons „ctlar n ao in cuing the v.ork authoriz- � This application is not a permit until
Ed thereo':, nO oe SOn v,l: bA emp;o%eo In vicia:i,3n of the Labor „_ E signea by the Building Official or his
Code o' the State of t':'asnincion relating t0 Workmen's Compensa- ^^ E Deputy; and fees are paid, and receipt is
!iomigsurance. _, acKnowledged in space provided.
OFFICIAL'S SIGNATURE
OF
EDMONDS \j'`L� L,:If ` r�� - I•.� y-
ATTENTION ;,
IT IS UP...+I'v'FL' IG �ijE O= CCtu Y : UI' 71.if.. OR STRUCTLRE
UJTiL A ' .AL INSPECTION III; .zLS BEEN, '.. v_ at -IC APPROVAL OR {�}y �} ORIGINAL — File YELLOW — Inspector
A CERT1=1CAT tom-:` 0CCUF:4NCN n. S 5C_ AINTED. UBC u 1984
O' APTER 3. APR PINK. — Owner GOLD — Assessor
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PERM It
CITY OF EDMONDSE NUMBER �x�(�;�'K:��t
CONSTRUCTION PERMIT APPL}
NAME (OR NAME OF BUSINESS) RESS
AL DESCRIPTION CHECK SUBDIVISIOW NO. LID NO.
1
w MAILING ADDRESS
O
IIICIT'r , TELEPHONE LIC FJIGHT OF WAt PER OFFlCIaL STREET R1AP
STING REQUIRED DEDICATIONPOSED...NAMEHT OF NlAY CONSTRUCTION i'EFiRnT HEOWREpAI�1'RES� EET USE PERMIT REQUIRED z i
0 _f...
I SEE ENGINEERING MEMO DATED w pz :I •y
NAt.1 F.
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ADDRESS
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CITY
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STATE LICENSE tNU1.18E9
Legal Description of F
(show below or attach
IPLEPr10NE NUMBER
TELEPHONE NUMBER
CITY LICENSE NUMBER
erty - include all easements
r copies)
E_! 'J Ev. RESIDENTIAL I PLUMBING
C1
I ADD ALTER NON RESIDENTIAL MECHANICAL
REPAIR RETAINING WALL SIGN
EXCAVATE FENCE
lJ DEMOLISH OR FILL f—f , ._.__1. 1 ....FT1
'-1 PRE MOVE INSP,I r� S'•VLM
F I
L.J SIDE SEWER EI WATER LINE
711
NULL BER OF STORIES NUMFRFROF
U\Ytt-LINU
V rii I',
NATURE OF WORK To BE DONE (ATTACH PLOT PLANT
SEE PAV DEPT P.PVIEN CHECK. UST DATED
SIZE IrjU)�.Ci I:G r.,. �'_V
c� A
SIGN AREA ENV. REVIEIV
ALLOWED PROPOSED COMPI.rTE EXEMPT
VARIANCE OR CU PLANNING REVIEW BY
YARDS
FRONT SIDE
ARKS
cO G1' TYPE OF CC.'JSTF
SPECIAL INSPECTOR I AREA ( OCCUPANCY
REQUIRED GROUP
YES NO.
REkIARKS
In -
VALUATION
ii
s, It
UNIT ;: I
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w ,
C tl, l !r;
ADB NO
i
SHORELINE 11
-- j
oarE
O
LOT COVERAGE
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HEIGHT
OCCUPANT
LOAD
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5UILDi:.G '
Yu n
i)lk
This Permit ho A , ,vork to be done On private pro e ty ONLY. GR
An\ CCnSIr IC ) nn The public dormain (Curt;S sidl vialkS.
drivcv;ays. marquees. etc 1 ,oil! reQuire separate permission.
Permit A.DDlicatern.. 150 Days
Permit Limit: 1 Year - PrOVIGe❑ Worr, i5 Siarlec V;ithin 1$0 Days
gpt-:ilcanf. ,n Ciehaif Of his Or her Spousehe!r5. assigns and
s,Nccessors (n intere<_1, agrees to Indemnity, defend and hold
i_ naftTlle SS tfie Cif', O! EcTmoncs. b%IasningtGn, Its Oificiai S.
x employees. ano agents from an,, and all claims fc.o damages of
< N/hateve! nature, arising dire Cl!\or tnairect! from fire issuance
of this per,,.it. Issuance of this cermit shall not be .._emec to
ffjCCiij}r,l',ive O reduce an•' 'e^yu,-e 'ni • f anP -:'y Did ina.n,ce
y
not IITit [*I-,-_ A.�I .� • r
a a} the Clr,'s at l,t: _ i. �e na any rdince •COUNT DUE t r_
prD\ ISIon. TOTAL
I hereby acknovOecge that I have read this a,. clicaiion, that the
information Given is correct; and that I am the owner, or the duly ATTENTION APPLICATION APPROVAL
authorized agent of the owner. I agree IC comply r.itP city and
state lav:s regulating construction aria !n acing the ;,or' authoriz. ." i This application is not a permit until
ed thereb\ no Derson ,\ill oe emD e,ec in. \io,ation of the Labor ;r signed by the Building Official or his
Code c4 the State o; 1:'asr.inc:en rratmc tD 4.o kmen's Compensa- or Deputy; and fees are paid, and receipt is
Lion Risurance. acknowledged in space provided.
p-u47
r I I Y Q= OFFICIALS SIGNATURE \ yy
KI
EDNIONiDS
ATTENTION ,il. zo
IT iS lutNLI% F;,iL TO USE vR CCCi.IPY EJI_Di,'+Ci OR STRUCTi)RE
UNTiL A i':SPECTICN HAS SEE% tC DE :') APPROVAL OR ORIGINAL — File YELLOW — Inspector
�ERTiFIC TE OF .^.CCU!=ANC\' %^AS E E E uRA?:TED. U3C APR 18 1984
pTER PINK -- Owner GOLD — Assessor
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ENVIRONMENTAL CHECKLIST
A. BACKGROUND
1. Name of Proponent i.J'� •t � � 4
2. Address and Phone Number of Proponent
3. Date Checklist Submitted
4. Agency Requiring Checklist
5. Name of Proposal, if applicable
6. Nature and Brief Description of Proposal (including but not limited to
its size, general design elements, and other factors that will give an
accurate understanding of its scooe and nature:
7. Location
of
Proposal (describe the
physical setting of the proposal, as
well as
the
extent of the land area
affected by any environmental im-
pacts, including
any other information
needed to give an accurate under-
standing
of
the
environmental
settinq
of the
proposal):
8. Estimated Date for Completion of the Proposal)
9. List of all Permits, Licenses, or Government Approvals Required for all
Proposal (federal, state, and local — including rezones): 11
10. Do you have any plans for future additions, expansions, or further
activity related to -or qonnected with this proposal? If yes, oxplaln.,
�� i'�^-"' i./%.✓, / .�..c'�' ✓�^r/ f.(.i/ Lam' ✓ `
11. ,Do+ou'know of any plans by others which may affect the property covered
by xfmir nrnnncal? Tf vac aYnlain _
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