640123.pdfApplicant Fill
Permit Application I Inside Heavy Lines
R 5-0 1
MMLING ADDRESS
4 6�
CITY TELEPHONE NUMISI!�R
�(4r)k) W00t3 Pj?
NAME
00, i= v r-.- �? s
r
PERMIT
EAU I ZJ
NUMBER
DDRESS
YARD
SET BACK
REAR YARD,
MAP NUMBER
VACANT BMW
/ V0
IVIZ�
)O�7ES 13 NO
)ING AREA
LOT AREA
VARIANCE NUMBER
LIT
NOTE:
ALL BUILDING SETBACKS
TO EAVE LINES
I-= S 0 IV
FS
Encroachment Permit
PERMIT NUMBER STREET GRADE CHECKI
Required
r3 YES N 0
E
T LEPRONE NUMBM—
METER SIZE SERVICE SIZE CLEARANCE CHECKE BY
Z LICENSE NUMBER
CITY LICENSE NUMBER
MMARKS
14
L 0 T
B T
. 1
W Trz - to 4—c r
TYPE CONNECTION
VERIFIED BY
as
PERO. TEST/
PERMIT NUMBER
/S
-741,
FIRE ZONE TYPE
OF CONSTRUCTION STREET IMPROVED
I] YES NO
SPECIAL INSPECTOR
REQUIRED OCCUPANCY GROUP
[] YES 13 NO
I
PLAN CHECKED BY
e5ge4��L
WORK TO BE DONE
NO. Or BLOGS.
PERIBLOG.
TOTAL F99
BUILDING
VALUATION
2
BUILDING PERMIT
FEE
0--lirw
DEMOLISH
NUMBER OF STORIES
—
ADD
3
PLUMBING
PERMIT FEE
BEAT & GAB LINE
PERMIT FEE
ALTER
NUMBER OF
RESIDENTIAL
REPAIR
NON-RESIDENTIAL
DWELLING
UNITS
DEMOLITION
PERMIT FEE
AMOUNT DUE
.'C;'7 A9 jE
... In-
I hereby acknowledge that I have read this application: that the In-
ATTENTION
APPLICATION APPROVAL
1 or_
formation given Is correct; and that I am the owner, or the duly author-
re gu_
lzed agent of the owner. I agree to comply with city and state lawn regu-
THIS PEILNUT
This application Is not a permit until
roon
lating construction; and In doing the work authorized thereby, no Person
AUTHORIZES
signed by the Director of Building Inspec-
glen
will be employed In violation of the Labor Code of the State of Washington
ONLY THE
]1h
relating to Workmen's Compensation Insurance.
WORK NOTED
tion, or his deputy; and fees are paid, and
NOTE: PERMIT LIMIT ONE YEAR
receipt Is acknowledged in space provided.
;T
INSPECTION
DEPARTMENT
UGNA RE (OWNER OR ENT
DATE dICNED
01.
DIRECT 'S GNATURE
1
CITY OF
EDIVIONDS
DATE r
CII!��PPROVED
'Ir Pr
PR 6-1107
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