850074.pdfCITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
NAME (OR NAME OF BUSINESS)
PERMIT — NUMBER 85C074
TELEPHONE NUMBERPUBLIC
RIGHT OF WAY PER OFFICIAL STREET MAP.
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REOUIREDDEDICATION __ ........_..
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PROPOSED .. ... __.......
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED.-'
STREET USE PERMIT REQUIRED
SEE ENGINEERING MEMO DATED. - --------
TELEPHONE NUMBER
SEE PIW DEPT. REVIEW CHECK LIST DATED_... .. _.. _._-__._.. .—
CITY
T 355-77:
STATE LICENSE NUMBER CITY LICENSE NUMBER
1 Wool noanriot Ion of Prooertv - Include all easements
UNITS
ALLOWED I PROPOSED COMPLETE EXEMPT
SHORELINE M
VARIANCE OR CU PLANNING REVIEW BY DATE
YARDS LOT COVERAGE
PLUMBING
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RESIDENTIAL
ElADOIALTER
NON-RESIDENTIAL
MECHANICAL
ElREPAIR
RETAINING WALL
SIGN
EXCAVATE
FENCE
DEMOLISH
OR FILL
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NUMBER OF STORIES
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NATURE OF WORK TO BE DONE (ATTACH PLOT PLAN)
PLAN CHECK FEE
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PLUMBING
MECHANICAL
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
m successors in Interest, agrees to Indemnify, defend and hold
w harmless the City of Edmonds, Washington, its officials,
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
9 modify, waive or reduce any requirement of any city ordinance
i 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
ONLY THE
Code of the State of Washington relating to Workmen's Compensa-
WORK NOTED
tl n Insurance.
INSPECTION
SIGNATURE (OWNER OR AGENT) OATE/ SIGNED
DEPARTMENT
CITY OF
G
EDMONDS
ATTENTION
771.3202
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED.
UBC
CHAPTER 3.
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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.
FFICI L'S SIGNATURE
re
ORIGINAL — File YELLOW — Inspector
PINK — Owner GOLD — Assessor
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