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Applicant Fill
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NUMBER
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PERMIT APPLICATION Inside
Heavy Lines
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NAME OR NAME OF BUSINESSI
ADDRESS
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LEGAL LOT
LOT AREA SUBDIVISION
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COMP. PLAN ST. R/W i- FT. 'l FT.
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NAME -
REMARKS
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TELEPHONE NUMBER.
STREET AND/OR UTILITY WORK
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NAME
UNDERGROUND
WIRING REQ'D.
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TYPE CONNECTION
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VERIFIED BY
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SANITARY SEWER
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TELEPHONE NUMBER
SEPTIC SYSTEM
❑YES
PERMIT NUMBER
APPV'D BY CITY ENG.
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79TATE LICENSE NUMBER
CITY LICENSE NUMBER
REMARKS
Legal Description of Property (Show Below or Attach Four Copies)
METER SIZE
BUILDING UPPLY SIZE
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LOAD
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PLAN CHECKED BY
THIS SITE IS LOCATED IN THE CITY
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REPAIR � NSP. ❑
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NUMBER OF STORIES
NUMBER OF
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SWIMMING POOL
I hereby acknowledge that I have read this application; that the in-
TOTAL AMOUNT DUE
formation given is correct; and that I am the owner, or the duly author-
ized agent of the owner. I agree to comply with city and state laws regu-
ATTENTION'
APPLICATION APPROVAL
lating construction; and in doing the work authorized thereby, no person
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will be employed in.violation of the Labor Code of the State of Washington
THIS PERMIT
This application is not a permit
relating to Workmen's Compensation Insurance.
AUTHORIZES
until signed by the Building Official or
i
NOTE: Permit Limit One Year(Except DEMOLITIONS and FILL
ONLY THE
his Deputy; and fees are paid, and
PERMITS without conditional use permit, which shall be completed in 90
WORK NOTED
receipt is acknowledged in space pro -
days; MOVED -IN BUILDINGS shall be completed in six months.)
vided.
SIGNATURE OWNER OR AGENT
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DATE SIGNED
INSPECTION.,
DEPARTMENT
DIRECTOR'S IGNATURE
CITY OF
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:0..
Applicant Plan Check Fee
EDMONDS
775-2525
DATE 7
NOTE: -Subject to
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
ORIGINAL -File YELLOW -Ins Inspector
p
marquees, etc.) will require separate permission.
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GOLD - Assessor PINK - Owner