650469.pdfI
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ON KROLL MAP NO.: BUILDING
PERMIT
UILDING DEPARTMENT Applicant Fill NUMBER 650469
inside Heavy Lines JOB ADDRES13
PERMIT APPLICATION
fAME (OR NAME OF BUSINESS) 1 -7"
01 4��+
or
[3 YES
NO 01M _R
REMARKS
METER SIZE SERVICE SIZE
CLEARANCE BY
I
ICHECKED
I
REMARKS
I
TYPE CONNECTION
VERIFIED BY
1
09
PERC. TEST
PERMIT NUMBER
I
�1
(j YES [] NO
[] YES [3 rTO
BUILDING
VAL
Z
3L,j�&aL. 22D10tAr4 5' �_A't cl�n
BUILDING PERMIT
FEE
2
3
PLUMBING
PERMIT FEE
j
HEAT & GAS LINE
PERMIT FEE
NEW
ADD
DEMOLT
El SIGN
FENCE
NUMBER OF STORIES
1;
—
SIGN PERMIT
FEE
DEMOLITION
PERMIT FIX
ALTER
REPAIR
RESIDENTIAL
NON-RESIDENTLkL
or
XfNG
I UNITS
7
PROPOSED USE
8
AMOUNT DUE
6Lv
IDMAUOU
I hereby acknowledge that I have read this application; that the In-
given Is correct; and that I am the owner, or the duly author-
ATTENTION
APPLICATION APPROVAL
lating
relating
fted agent of the owner. I agree to comply with city and state laws regu-
construction; and In doing the work authorized thereby, no person
will be employed In violation of the Labor Code of the State of Washington
to Workmen's Compensation Insurance.
11xcept Demolitions which shall
NOTE: Permit Limit One Year be completed In ninety days.)
THIS rEMIIT
AUTHORIZES
ONLY THE
WORK NOTED
This application is not a permit Until
S igned by the Director of Building Inspec-
tion, or his deputy; and fees are paid, and
receipt is acknowledged in space provided.
NATURE to ER OR AGENT) DA SIGNED
M5
INSPECTION
DEPARTMEMO
CITY OF
8
OR's BIG ME
EDYLONDS
NOTE: Applicant Subicct to Plait Chcch Fcc
This Permit covers work to be done an private property ONLY.
Any construction an the public domain (curbs, sidewalks, drivewaYn.
marquess. etc.) will require separate perminslon.
PR 0-1107
2A i
FILE