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CITY OF EDMONDS
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USE PERMIT
ZONE NUMBERV'
JOB + �✓-� SUITE/APT #
OWER NAME/NAME OF BUSINESSJADDRESS
� %/_7 /�/ 6A ` LEGAL DESCRIPTION CHECK SUBDIVISION NOO. LID NO,cc w MAILING ADDRESS/ 1l / O /�-(�V /(-, )l y�/ //J/tZc�PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP
NAME
ZIP TELEPHONE NUMBE11 R APPROVED BY
�C�� EXISTING REQUIRED DEDICATION
/V ��/- /(/ PROPOSED
ZIP ITELEPHONE NUMBER
ADDRESS
CIJY ZIP TELEPHONE NUMBER
STATE LICENSE NUMBER
oLz)SO / f116
Legal Description of Property - include all easements
(show below or attach two copies)
Tax Account Parcel No,
I NEW 111211111111 RESIDENTIAL
ElADD/ALTER 0 COMMERCIAL
REPAIR APT. BLDG.
EXCAVATE, El DEMOLISH OR GRADE FILL
CARPORT
REMODEL GARAGE
❑ WOOD STOVE/ ❑ RETAINING WALL/
INSERT ROCKERY
TYPE OF USE, BUSINESS OR ACTIVITY) EXPL/
NUMBER OF STORIES
NATURE OF WORK TO BE
/c.
NUMBER OF
DWELLING
UNITS
(ATTACH PLOT PLAN)
LJ PLUMBING
n® MECHANICAL
E, SIGN
❑FENCE
I. x _FT)
f-1 SWIM
11 RENEWAL
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED ❑
STREET USE PERMIT REQUIRED ❑
SEE ENGINEERING MEMO DATED
REMARKS
METER SIZE (BUILDING SUPPLY SIZE (FIXTURE UNITS
REMARKS
SIGN AREA ENV. REVIEW
ALLOWED I PROPOSED COMPLETE I EXEMPT
VARIANCE OR CU
SETBACKS - FEET
FRONT SIDE
ll
PLANNING REVIEW BY
REAR
M
ADB NO.
DATE
HEIGHT I LOT COVERAGE
OF CCOONSSTRUCjTION CODE
HEIGHT
SPECIAL INSPECTOR AREA OCCUPANC OCCUPANT
REQUIRED GROUP LOAD
n YES L: NO
REMARKS
PROGRESS INSPECTIONS PER UBC 305
FINAL INSPECTION REQUIRED
7 VALUATION
PLAN CHECK FEE
BUILDING
C%Q Q A) PLUMBING
Plan Check No. �40 /DC,2 ULf % MECHANICAL
This Permit covers work to be done on private property ONLY. GRADING/FILL
Any construction on the public domain (curbs, sidewalks,
driveways, marquees, etc.) will require separate permission. STATE SURCHARGE
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
N successors in interest, agrees to indemnify, defend and hold
J harmless the City of Edmonds, Washington, its officials,
employees, and agents from any and all claims for damages of
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whatever nature, arising directly or indirectly from the issuance PLAN CHECK DEPOSIT
0 of this permit. Issuance of this permit shall not be deemed to
0modify, 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
information given is correct; and that I am the owner, or the duly ATTENTION
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
tion Insurance. INSPECTION
SIGNATURE (OWNER OR AGE TI DATE SIGNED DEPARTMENT
J��� //1 `/ f��%I jar CITY OF
�t r ��« / l_( / EDMONDS
CALL FOR
ATTENTION INSPECTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE 771-3202
UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR
A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. UBC
CHAPTER 3.
102.87
FEE
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.
FI 'S IGN URE YrATE
1 FASFII DATE
ORIGINAL
— File
YELLOW
— Inspecto
PINK —
Owner
GOLD —
Assessor /
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