840324.pdfIRIGHT
- PERMIT
CITY OF EDMONDSP,S� 7 NNMDER,�,,,N
CONSTRUCTION PERMIT APPLI
- NAME TOR NAME OF BUSINESS)
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MAILING ADDRESS
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CITY t TELEPHONE NUIC RIGHT OF WAY PER OFFICIAL STREET MAP.
7 r / - _ / 1ING _.. .. REQUIRED DEDICATION
OSED __..
NAME .__.
T OF WAY CONSTRUCTION PERMIT REQUIRED
ET USEPERMIT REQUIRED
w ADDRESS
SEE ENGINEERING MEMO DATED. ..
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riTc �—T7 ELEPHONE NUMBER SEE PIl"r' DEPI REVIEW: GiiECK LIST DA?E9D
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ADDRESS ii.,'W.% •mil :' �l
METER SIZE F!ZF F '-URE UNITS
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CITY TELEPHONE NUMBER -"�• ply(;
STATE LICENSE NUMSEP C!TV LICENSE NVIJ
c"NV. REVIEW ADB NO.
POSE" COMPLETE EXEMPT
Legal Description of Property p include all easement
(show below or attach four copies)� SHORELINE"
4' VARIANCE PLANNING RF' IEYN BY �TFLID COVERAGE
`.'�IUE
RESIDENTIAL PLUMBING
ADD,ALTER � NON RESIDENTIAL MECHANICAL
REPAIR RETAINING WALL. SIGN
'—' ETCA\'ATE (—� FENCE
CHECKED BY I tP:%E O' i'O!aS Tii C'C;TION CODE NEIGH?
Li DEMOLISH OR FILL (_f i FT l V
PRE MOVE INSP; SWIM SPE01.41 INSPECTOR %•RE4 OCGUPANCYOCCUPANT
COMPLIANCE INSP POOL REQUIRED 'GROUP LOAD^....I �, YE5 NO
CSIDE SEINER I `:DATER LINE RE!'-!ititi
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U IY LLL1NLi
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tJA iliRE OF I.^. EE DONE jATT AC!i FLOT PLANT
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This Pem ;; c.r:Prs •vork to be done on private property ONLY'. GRADI,:i; `I_ --- -}--
An; ci'.st c +.' on the public domain (7!:rbs side'::aik.s,
drive+:2y5, nara.Jees. etc.) :'•ill require separate permission. I
Pet'r,-; Appllratig,;a' t 50 Oays
Permit Limit. T year . Proaidee 4VOrk is Started vV'ith!n 180 Days
cn behalf of his cr ner spouse. hears. assig4ns and
essors Ir. Intares;. agrees to indemn!f,. Ccfenu" and 'hold
5�ha;rnless the Cit4' of Edn iond$. :�'aShirlgt Oln, 119 v1fIC131 S.
eR10IQI,ee5. and a enr.z, trom am ,n d all claim`; f0 u a' ages 04 I
Yhateler nature. arising, dir lily or Inclre 1 rom he issuance
Of this Derml+. IsSUa'..e O+ !his permit snail nor h„ 'dee .ed i0 i ,( �` '( EI[_
m odlf';. .A aiee Or reduce ariv requirement of a1' Gh� ordinance
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nor Emit in am' ::'ay the Cit';s ab1!!ty ra enForce a ordinance 7OT.AL Ah10U(%iT DUE I _
Drovis1 on.
I hereby acNnoly!edge that 1 have rea0 t" s , �ca,lor- that trio
information giver is correct and that I a- nE ii rer, of the duty ITENTIOIN I APPLICATION APPROVAL
authorized agent of the oI•:rcr. I acree to om„iy vith city and
state lar,s reculat!ne co�s;r,c!to". and n dcinu the :vork a-utnonz. F This application is not a permit until
ed there"';. ro zerson vil; ce employe; in iolanon of line Labor ;E ! signed by the Building Official or his
Code of the State of IYas n.ngtcr: !? ting tc 1'•; Orkmcn's Compensa "r L, _ f Deputy; and fees are paid, and receipt IS
tion Insu an c , acknowledged in space provided.
_CITy OF OFFICIAL 5 StGNATURE �{ ram,,
ATTENTION L G �? 4
IT IS UNLyIIPU O USE ? .;C..UPr A L 'DING � STPUCTURE
UNTIL A FINAL IN St ECTION -+AS E': ` ":)E AND APPROVAL 0 J 19C�4 ORIGINAL — rile YELLOW — Inspector
A CER.irICATE .O- O.�UPANCf ,AS t?: un tVTED U3 ,'T` j
C i 4 PT ER 0 PINK — Owner GOLD — Assessor
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1 . Name of Proponent T3�c°Jl.c �: %r /� r' 6 c� rt�rti
2. Address and Phone Number of Proponent44949 Kiel
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3. Date Checklist Submitted
4. Agency Requiring Checklist ,F y
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 ProposalZ4(()
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.
11. Do you know of any plans by others which may affect the property covered
by your proposal? If yes, explain..
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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: