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BUILDING DEPARTMENT Applicant Fill 20NE� i% �C/ NUMBER
1
PERMIT APPLICATION Inside Heavy LinesJOB
NAME (OR NAME OF BUSINESS) ADDRESS Z a,a /P _ `1 N
E �. LEGAL LOT PLAT NAME SUBDIVISION NO.
OYES [INC)
W MAILING ADDRESS
y I ?�g �� � PUBLIC RIGHT OF WAY PER ORDINANCE NO.
0 CITY TELEPHONE NUMBER
� ��/�� J' -/ �EXISTING RIGHT OF WAY0D
PROPOSED RIGHT OF WAY �'i�/ 0
NAME
DMQ2E�✓✓ DEFICIENCY OF RIGHT OF WAY D
I. G
W ADDRESS / p STREET/UTILITY WORK REQUIRED YES NO
�"NE IOP:�y.r PERMIT FOR WORK IN PUBLIC R/W INYES El No
W •4•K-/ TELEPHONE NUMBER UNDERGROUND WIRING REQUIRED ❑YES ®NO
Q CITY �i
� .��` ram] ce /l L 2��-� y / � CONNECTION TO SANITARY SEWER DYES NO
/ V SEPTIC TANK PERMIT REQUIRED DYES iNNO
NAME
SEPTIC TANK PERMIT NO.
O ADDRESS SEE MEMO DATED
F
U
Q TELEi: NE NUMBER REMARKS
I- CITY Np.. I- t i
2
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U 7gTATE LICENSE NUMBER CITY LICENSE NUMBER CHECKED BY
METER SIZE. BUILDING SUPPLY SIZE
Legal Description of Property (Show Below or Attach Four Copies) * 41
fir--/ 94& 3 114k6 Aefe'IN64�22 1Wo REMARKS
IY�AT S�.c�oivisioN less PR�ssvtZs Q�f�vc.a-roR R o NO.
SIGN AREA ENV. REVIEW
��'�i�,• ALLOWED PROPOSED COMPLET EXEMPT
-40 �?' /7V (� I SHORELINE
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n C4 ,iV S �i/ ra J REMARKS
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J VIEW BY DATE
VARIANCE OR CU PLANNING RE
YARDS / (( LOT COVERAGE
aFRONT SIDE f ,er�REAR OK
GAS
Q NEW RESIDENTIAL LINE FIRE ZONE TYPE OF`rCONSTRUCTION CODEQ HEIGHT
❑ NON-RESIDENTIAL ❑ SIGN V - I 1 1 2S fl
❑ OCCUFA
ADD RETAINING SPECIAL INSPECTOR AREA OCCUPANCY /� LOAD
ElDEMOLISH yy
❑ LOAD
WALL REQUIRED IQ GROUP
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ALTER- EXCAVATE FENCE El Yes
flO OO ►1+ 1�
OR FILL ❑ ( X �) PLAN CHECKED BY OF EDMONDS.SALES
OLOCAL (1
TY
❑ TAX
REPAIR PRE -MOVE OSwim }. SHOULD HE CODED 31.04.
INSP, POOL
REMARKS
Z NUMBER OF (201
STO=7DWELLING
R OF / `A,TI� a, 80
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a NATURE OF WORK TO BE DONELOT Q 7c�
N 41eW 6mW STt Cr7o
o P oGzess 1 1?E; T1dNs 12EQD•_
m PLAN CHECK FEE VALUATION FEE
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n PROPOSED USE /-
Nov A&I=-5ID&W56F_
PLOT PLAN INDICATE BUILDING S
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"Applicant, on behalf of his or her spouse, heirs, assigns and
a successors in interest, agrees to indemnify, defend and hold harmless
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f the City of Edmonds, Washington, its officials, employees, an
M agents from any and all claims for damages of whatever nature,
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T arising directly or indirectly from the issuance of this permit. ssu-
o ante of this permit shall not be deemed to modify, waive or reduce
o any requirement of any city ordinance nor limit in any way the
x City's ability to enforce any ordinance provision."
1 hereby acknowledge that i have read this application; that the in-
formation given is correct; and that I am the owner, or the duly author-
ized agent of the owner. 1 agree to comply with city and state laws regu-
lating construction; and in doing the work authorized thereby, no person
will be employed in violation of the Labor Code of the State of Washington
relating to Workmen's Compensation: Insurance.
NOTE: Permit Limit One Year(Except DEMOLITIONS and FILL
PERMITS without conditional use permit, which shall be completed in 90
da ; MOVED- N BUILDINGS shall be completed in six months.)
(GNAT (O NECf��GENT) DATE SIGNED
Thist0armit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marquees, etc.) will require separate permission.
BUILDING
PLUMBING
MECHANICAL
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
AMOUNT DUE
ATTENTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
775-2525
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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 pro-
vided.
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