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USE PERMIT �t t I 3
CITY OF EDMONDS ZQIJE NUMBER �rfi0ayi:
CONSTRUCTION PERMIT APPLICATION 1:
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ADDRESS
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LEGAL DESCRIPTION CHECK Sufi DIVISION NO LID NO. �..
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CITi rLLEPHONENWABER PUBLIC RIGHT OF WAY PER OFFICIAL. STREET MAP. '
Q, ! EXISTING _. _ _. _.._ REQUIRED DEDICATION
NAME PROPOSED
RIGHT OF WAY CONSTRUCTION PERMIT REQUIRED w ��
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ADDRESS STREET USE PERMIT REQUIRED
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SEE ENGINEERING MEMO DATED - I++
CITY TELEPHUME NUMBER SEE. PIVII DEPT_ RFVIE:+ CHECn LIST DATED
REMARKS � t
NAME /[.4/:/ �� 1"(4 �j�'�'J�it�[_ l�✓r. Lei' � t3
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STAY LICENSE NUMBER CITY LICENSE NUMBER
SIGN AREA EN). HEVIEIV ADD NO, P.
Legal Description of Property - include all easements nuoe:ED PROPosED COMPLETE ExE:+,F+
(show below or attach four copies) A ;„ sHoaet.INe a
G //' �' •�-- VARIANCE OR CU PLANNING REVIEVI B'/ ._ DATE
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G YARDS LOT COVERAGE
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NEW RESIDENTIAL LI PLUMBING
-I rEl ADDIALTER rIL—�7I� NON 9ESIDENtfAL ;r�TI MECHANICAL
17 ncunlR f I RPTAINING WALL L..l SIGN
EXCAVATE ❑ FENCE
DEMOLISH OP FILL
I-7 PRE MOVE INSP,
t i ❑E {�jj SIDE SEWER I I %%ATER LINE
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NUM'3 E'. Jr STORIES NU%!RFROF
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C:'OFr; TC BE. DONE iA'r i'AC:-t PLOT P:ANI,
CHECKED BY TYPE O: CnNSTRUCTIOtd CODE
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SPECIAL INSPECTOR AREA OCCUPANCY
REOUIPED GROUP
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R EI, ,RKS
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This Pe^":'; ce:'ars ;tor: to be done on1privnte r :operty ONLY. Gt;ADc.G FI._
A^ c cn tie publl1 drma;n ;curbs. sldevvalks.
enlC : vill require separate perrnission.
Peer-• � �I,.al C '� DaV�
P.ern?il Um:!. 1 Year - P'OVIded F•:'Ori. is Startec t'litnin 180 Days
! =. EilritCar?t. Of-, beh.40 Of hIS U' her SpOUSe. heirs, dSSignS and
.esSDra in mtetest. agrees to mderrn-fy, derend and hole
tharnlless the City of Edmonds. :Vashinc+on• Its OfflCial S.
E employees, aril aGan.'S from arty anC aii G31 nTS iCr .'.amaQBS Gf
l,,haievo' nature aistng di'ectly o Inoire.-tl,P`rom ;ne ;Ssuance
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Of this DermIt. ISSCr.n Cb 01 this Lermlt She'' �i be des^med i0
C-� nTOdifM1 'aiVe or reauce ant- ream e-nent am o yI nance
nor limit In an, t?•: 'h_ Ctk"S ahi m !o c. '. .,., _. J ;,L:-srCe TCT -L APa1CUrJT DUE
pro�islcr
I hereby ackro+1eece that I have reaa to a cat;en that the O
informatic.n ciae '< ccr.ecr, and ilhat I a^- orear or the duly
authorized agent of the e:vner. I agree to ccmpl•' with city and _
state lawj reg Ulatlnc JCnstl'uCt10r:: and in d0?ng the h-Qrk authori'.
ed thereby. nD ;.`e•rs0r, l:il: be employed III •:iCiat?on of the Labor
Code 01 ine State of ilffivlasrl I r'. •Or . !I. I g t0 Worn,r*'en'S Compensa-
tion Insurance. Sr= T C
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ATTENTION `' ``�2
IT IS U'v' -U' �S= O OCC _ I D NG OR STRUCTU^E
I,NTIL 4 INAL ,:SPEC710N nAS 9 _'� Iv i Cl E AND AEPPOVA L 0R j] ry j(] /� ti CE-R7i=ICA'E E O��L?.-`,�:r'Y —1=.5 ..__ GR4NTED. U9!1ID1\ 1 � I.J�`C
tiAPTER
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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 i
acknowledged in space provided.
OFFICIAL'S SIGNATURE '1
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ORIGINAL — File YELLOW — Inspector t(I
PI14K — Owner GOLD — Assessor
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BACKGROUND
1. Name of Proponent
2. Address and Phone Number of Proponent 'z��,(�
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3. Date Checklist Submitted r
4. Agency Requiring Checklist
5. Name of Proposal, if applicable
6. Nature and Brief Description of Proposal (including but not limited to
its size, general design elements, and other factors that will give an
accurate understanding of its scope and_,nature:
7. location of Proposal (describe the physical setting of the proposal, as
well as the extent of the land area affected by any environmental im-
pacts, including any other information needed to give an accurate under-
standing of the environmental setting of the proposal):
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8. Estimated Date for Completion of the Proposal
9. List of all Permits, Licenses, or Government Approvals Required for all
Proposal (federal, state, and local — including rezones):
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10. Do you have any plans for future additions, expansions, or further
activity related to or connected with_this proposal? If yes, explain.
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11. Do you know of any plans by others which may affect the property covered fr
by your proposal? If yes, explain. 1
12. Attach any other application form that has been completed regarding the
proposal; if none has been completed, but is expected to be filed at �.
some future date, describe the nature of such application form:
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