122 4TH AVE S.PDF122 4TH AVE S
APPLICATION
for
The City of Edmonds SIDE SEWER PERMIT
EASEMENT No . ..........................................
NEW CONSTRUCtION 0 REPAIRS 0
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OWNER................ R-knell ...... E, .......... ........... ............... ........ CONTRACTOR ................................................................................................... PERMIT No . ......................
ADDRESS ......... ... 4-th ... Ave. ... ... S . . ......................... . ............... rear.DESCRIPTION: LOT No. .............................................. BLOCK No. ............................................
--- ----- .. .....
NAMEOF ADDITION ....................................................................................... .................................................
II
Dye Tested On Sewer
June, 1972
Approved:
DATE................................................ By .......................................................... ............
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CITY of EDMONDS BU40ESS LICENSEE APPLICATION DFW/,2—,�n LICENSE NO.
Civic Center • Edmonds, Washington 98020
a City Clerk Phone 775-2525 ANNUALfreES PENALTY AFTER FEB. 15
E7IEET FILE HOME
_
OCCUPATION
�'STRUCTIONS:
CLASS
YEAR I LIC.
HeLc. OAIL
AEA::
c, Lac NCI
:,PrC
$10.00 (A) ADDITIONAL $5.00 ❑
All items must be completed
❑ SMALL BUSINESS
or application will not be aC
RECEIPT NO.
DATL :AID
PR!NT'X'
$15.00 (B) ADDITIONAL $7.50 ❑
cepted.
IN SPEC. BOX OF
FOR ISSUE OF
❑ Business with 10 or
n SI and return application
g
FEE PAID
PENALTY PAID
CORRECTED
more employees ADDITIONAL $25.00 ❑
v. ith fee. Renewals received
I
I
LICENSE WITH
LC' ACTION.
$50.00 (C)
,-Ater February 15 must pay
❑ NEW APPLICATION (LA)
penalty in addition to fee.
L] RENEWAL (LB)
NEW BUSINESSES AFTER
❑ CHANGE (LC)
JULY 31, 1/2 FEE. (PLEASE MAKE ANY NECESSARY CHANGES) ❑ DELETE _ (LD)
NAME OF FIRM
BUSINESS PHONE
NO. OF E ?,"PLOYEES
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4 1 G QA
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-4
MAILING ADDRESS
-Zz A— h&
NATURE OF BUSINESS
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t-tU
1�� �cob
e a/ &W
BUSINESS ADDRESS INDIVIDUAL PARTNERSHIP CORPORATION
��-1 /ve _ ]_ (S) = (P) = P
O"1INERS NAME 1-;01MIE ADDRESS OVA ON) -0S
-7+;5 PHONE 4�13 DATE OF BIRTH t FLAty;
EMERGENCY NOTIFICATION: (1) NAME & TELEPHONE
(PLEASE LIST TWO) (2) NAME & TELEPr-IONE
F L3IFIT H
A Cv
WASHINGTON STATE TAX NO. APPLICANT'S SIGNATURE
DO NOT WRITE SFLOW THIS LINE
ST/4fFF REVIEW:
SOCIAL SECURITY NUMBE
FILL IN LAND USE CODE, UFIR NUMBERS, ZONING, ETC. CHECK APPROVAL OR
DISAPPROVAL, DATE, AND SIGN. IF DISAPPROVAL, PLEASE COMPLETE "COMMENT"
SECTION. ROUTE TO NEXT DEPARTMENT ON LIST.
PLANNING DEPARTMENT ° DATE LAND USE CODE ZONING CODE
APPROVE ❑ DISAPPROVE I r
SIGNATURE
CONDITIONAL USE PERMIT
COMMENTS
BUILDING DEPARTMENT DATE I !�
APPROVE ❑ DISAPPROVE SIGNATURE
COMMENTS:
CAPACITY: (NO. UNITS, APTS., OFFICES, SEATS, BEDS, STUDENTS)
FIRE DEPARTMENT
><--APPROVE ❑ DISAPPROVE
Building
❑
Hotel/Motel
(L)
Permit
❑
❑
Apt. Bldg.
Office Bldg.
(A)
(0)
Occupancy
U
Restaurant
(R)
Group
❑
Hosp/Nurs Home
(H)
❑
School
(S)
DATE rz- s 7 �ei— U.F.I.R.
SIGNATURE
COMMENTS:
POLICE DEPARTMENT DATE SIGNA-iURE__
APPROVE ❑ DISAPPROVE
COMMENTS:
PUBLIC tAJORKS DEPARTMENT 2
L APPROVE U DISAPPROVE DATE
SIGNATURE J4 d to
COMMENTS:
PLEASE RETURN YG, 0, 7 OLD o ii�
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