640247.pdfa
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Building
Permit Application
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PERMIT
.Ippllcant
side Heavy Lines
NUMBER
NAME (OR NAME OF BUSINESS)
JOB ADDRESS r3 "a Q, _4�%.,?A �, '.
90 �2
_5�4_
MAILING ADDRESS
SIDE YARP
SET BACK
REAR YA1113
CITY
TELEPHONE NUMBBII�R
NE
MAP NUMBER
VACAVT brrN
UL) (o(_�(.)0
NO
NAME
BUILDING AREA
T AREA
VARIANCE NUUBE
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AD13HESS
;HT
L BUILDING SETBACKS
NOTE:
TO EAVE LINES
CITY
TELEPHONE NUMBER
REMARKS
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NAME
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ADDRESS
Encroachment Permit
PERMIT NUMBER
GRADE
-UITY
LL." -
Required
YES [I NO
ISTREET
TELEPHONE NUMBER
METER SIZE
SERVICE SIZE CLEARANCE
CHECKED BY
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SPF81—A-� INSPLECT 11
YES
PLAN CHECKED BY
WORK TO BE DONE
BUILDING
I VALUATION
BUILDING PERMIT
NUMBER OF STORIES 2 FEE
NEW DEMOLISH PLUMBING
ADD 3 PERMIT FEE
HEAT & GAS LINE
ALTER RESIDENTIAL NUMBER OF 4 PERMIT FEE
DWELLING
REPAIR NON-RESIDENTIAL UNITS 5 DEMOLITION
PERMIT FEE
L_ kC _� I UC jj 6 AMOUNT DUE
I hereby acknowledge that I have read this applicELtion; that th In-
formation given Is correct: and that I am the owner, or the duly Mar- ATTENTION
ized agent of the owner. I agree to comply with city and state laws regu. THIS PER511T
lating construction: and in doing the work authorized thereby, no person AUTHORIZES
will be employed In violation of the Labor Code of the State of Washington 0114LY THE
relating to Workmen's Compensation Insurance. WORK NOTED
NOTE: PERMIT LIMIT ONE YEAR ECTION
SIGNATURE (OWNER OR ACIENT) DATE SIGNED INSP
/ / DEPARTMENT
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C;r-, �� -1 CITY OF
PLO?�L_A7 CHE BOND= EDMONDS
_��PROVED
Pit 6-1107
FILE
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STREET IMPROV�
[j YES [3 NO
PERIBLOGs
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APPLICATION APPROVAL
This application is ,lot a permit until
signed by the Director of Building Inspec-
tion, or his deputy; and fees are paid, and
receipt is acknowledged in space provided.
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