880091.pdfUSE PERMIT 0 �
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CITY OF EDMONDS
PERMIT APPLICATION A
CONSTRUCTION ADDRESS ® G'
NAME (OR NAME OF Bill III USINESS)
LEGAL DESCRIP ION CHECK SUBDIVISI N N0. LID NO.
f ' I i/
w MAILING ADDRESS
Z ' L G P PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP.
TELEPHONE NUMBER
CITY � EXISTING REQUIRED DEDICATION — z ,
PROPOSED
1J
NAME w
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED i7 Z
STREET USE PERMIT REQUIRED ; -. Z
z
w
w ADDRESS SEE ENGINEERING MEMO DATED
r
TFi FaHONE NUMBER
NAME
CIO RTAL
ADDRESS
I 6 ( 4VI- &V �, S
CITY
ems- EA�TL-G-
STATE LICENSE NUMBER
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(shoaw below or attach Property
cop
NUMBER
all easements
CJ NEW EL.JRESIDENTIAL L: PLUMBING
ADDIALTERCOMMERCIAL Cl MECHANICAL
REPAIR C� RETAINING WALL El SIGN
EXCAVATE ❑ FENCE
DEMOLISH OR FILL swim
PRE-M( x
C� REMODEL COIIIIMPLLIIANCEVE SINSP. POOL
WOONS TOVEI ❑ RENEWAL
APT. BLDG
NUMBER OF
NUMBER OF STORIES DWELLING
UNITS
NATURE OF WORK TO 6E DONE (ATTACH PLOT PLAN)
METER SIZE BUILDING SUPPLY
REMARKS
E'(15T►►�v
SIGN AREA
ALLOWED I PROPOSED
VARIANCE OR CU
ENV. REVIEW
COMPLETE I EXEMPT
PLANNING REVIEW BY
YARDS
FRONT SIDE REAR
BY TYPE
/O�F�CONS'
SPECIAL INSPECTOR
REQUIRED
❑ YES ❑ NO
UNITS
M
w
3
ADB NO.
SHORELINE N
DATE
HEIGHT LOT COVERAGE
GROUP
OCCUPANT
LOAD
O
Z
Z
Z
Ig
0
Z
PROGRESS INSPECTIONS PER UBC 305
PLAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
Il This Permit covers work to ne on private property ONLY.
be doGRADINGIPILL
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission. STATE SURCHARGE
Permit Application: 180 Days ENERGY CODE
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,nd all claiims fortdamages officials,
employees, and agents from any fro m PLAN CHECK DEPOSIT
owhatef thisver permit. Issuance of this perm tor rshall no behdeemed toMWWWOMMMMI
modify, waive o way the City s requirement
totof enfo ce any ordinance ordinance TOTAL AMOUNT DUE
nor limit in any
provision."
I hereby acknowledge that I have read this application; that the ATTENTION
e owner, or information given is correct; and thatIm tcomply with city and THIS PERMIT
authorized agent of the owner. I agreeork ONLY THE
state laws regulating construction; and idoing then of theLabor
AUTHORIZES
ed thereby, no person will be employed
WORK NOTED
Code of the State of Washington relating to Workmen's Compensa- INSPECTION
tion Insur nce. DATE SIGNED DEPARTMENT
SIGNATUR 11(OWNER OR AGENT) CITY OF
_ �Z. 'G.. EDMONDS
lit ri
77 -3202
ATTENTION
IT IS UNLAWFUL
INSPECTION HOAS BEEN MADE CCUPY A BUILDING
APPROVAL OR
UNTIL A FINAL
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED, UB
CHAPTER 3.
102.87
VALUATION
22
APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or his
Deputy; and fees are paidreceipt is
acknowledged in space provided.
JE
OFFIC AL'S SIGNATURE �- , �^RELEASED BY:ORIGINAL — File YELLOW —
PINK — Owner GOLD — Assessor C/
House.
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