650250.pdfBuilding Permit Appit
NAM
ej (OR NAME OF BUSINESS)
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MAILING -ADDRESS
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CITY
ADDRESS
CITY
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PLAN FILE NUMBER BUILDING
Applicant Fill PERMIT
ition lInsid, He NUMBER 650250
00
106Q Al 7[ ,? o o - .1 7-
SIDE YARD SET BACK. REAR YARD
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in— phi a el -14", (4
FWORK TO VE DONE/,
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Required
1`1 YES M NO
LJ NEW L_j DEMOLISH
D"�ADD
ALTER DENTIAL N R OF
D=ELJNG
R REPi F� NON-RESIDENTIAL UNITS I
I hereby acknowledge that I have read this application; that the in-
formation given Is correct; and that I am the owner, or the duly author-
Ized agent of the owner. I agree to comply with city and state laws regu-
lating construction; and in doing the work authorized thereby, no person
will be employed In violation of the Labor Code of the State of Washington
relating to Workmen's Compensation Insurance.
NOTE: PERMIT LIMIT ONE YEAR
PLAN CgZCX & APPROVED
[] YES 0 NO
VACANT SITE
YES [3 NO
VARIANCE NUMBER
ALL BUILDING SETBACKS
NOTE: TO EAVE LINES I
STREET GRADE CHECK I
CHECKED BY
[] YES [] NO
Z�
NO. OF BLDG5.
PERIOLDG.
TUTA� r&M
z
0
BUILDING
VALUATION
2
BUILDING PERMIT
FEE
PLUMBING
3
PERMIT FEE
HEAT & GAS LINE
4
PERMIT FEE
DEMOLITION
5
PERMIT FEE
6
AMOUNT DUE
ATTENTION
APPLICATION APPROVAL
THIS PERMIT
This application is not a pernift until
AUTHOIUZES
ONLY THE
WORK NOTED
signed by the Director of Building Inspec-
tion, or his deputy; and fees are paid, and
receipt is acknowledged in space provided.
INSPECTION
DEPARTMENT
DIRECTOWS SIGNATURE
CITY OF
EDMONDS
Pit 0-1107
DATE
-4
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