M-116-67.pdfIMPORTANT! Press Firmly While Writing Application!
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Reioea4i®n Permit IDsldO Ileavy Lines
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PERMITy-
I NUMBER dA
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ANEW SITE ADDRESSIV
7
EDMONDS PRE -MOVE Aj
PERMITTION NO. �j 7y
DRESS
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TEL. NO.
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TIRE BLDG. PERMIT NO.
I WORK
3 I FOR WOR
,ONE AT NEW SITE
MOVE CONTRACTOR'S INSURANCE COVERAGE
TRACTOR
YN H_ 0 u C ! r 1 L� I� _ NAME OF SURETY
STREET ADDRESS j�� ♦ PROVIDING P.L. &
/ l f� / Y �i(./; P.D. COVERAGE10? __. /G sr r���.///✓��/..�+!'.!/>..i _r.l
CITY & ZONE I- TEL. NO.
FAT7/ 9�� 7 � ,� , Z/ � y
CONTRACTOR'S STATEA r�
CITY BU
LICENSE NO. s?;Z3_'0 115 LICENSESINO. `....._-
SITE DESCRIPTION
ADDRESS OF PRESENT BUILDING SITE
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Legal Description of Present Bldg. Site — (Show below or attach Pour copies)
i7 `7—, / 3 o �' k,/ /yL C aR 5, (
7-fi To
ADDRESS OF NEW BUILDING SITE
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r......., nnvn�inHnn n1 1h,w Itldc. tit, — f9hnw below or attach four copies)
iAREIJ t3Y :
Power Company ❑
Telephone Company
MAIL Q1rHOME ADDRESS
I hereby acknowledge that I have read this application; that
the information given is correct; and that I am the owner, a
duly licensed moving contractor, or the authorized agent of one
of these. I agree to comply with city and state laws regulating
building relocation; and in doing this work, no person will be
employed in violation of the Labor Code, State of Washington
relating to Workmen's Compensation Insur�lance.
Signature of Owner
Contractor, or /
Authorized Agent (........ V[ �Z -� C :ij......... .................. ..
Signer's /6'7 f vG �{/lGi Phone AA y���p..
Address .................................... /....I
............ .. No. /..... 1........ .... 1.-
.... ../.../...L-..'��. ....... 'l./`..............................
city - / )
Date -. l� !.[.�. c� ' /
VALID INSURANCE POLICY CHECKED BY: DATE
BUILDING DESCRIPTION
DESCRIBE BASIC CONSTRUCTION & PRESENT USE OF BUILDING:
OVERALL LENGTH OF BUILDING: IS-6 FT.
[EIGHT AS LOADED
WIDTH
BLDG. AREA
c� "a' FT.
2�ASlLOADED
.cJ V FT.
I (s 0 SR. FT.
POLICE DEPT. APP OVAL OF MOVING ROUTE
DATE
B
V
0
a
Time to Commence Moving: ............................................................
Time to Finish Moving: ....................................................................
FIRED PARTMENT CLEARANCE OF ROUTING
DATE
i
�- /3 -G 7
11
By: �zk �i�
ENGI '�CLEARANC
$
DATE00,
/J
RELOCATION
RECEIPT NO.
FEE s / /
ATTENTION:
THIS PERMIT
AUTHORIZES
ONLY THE
RELOCATION
OF THE
BUILDING
NOTED
BUILDING
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PR 6-1107
P C
PERMIT APPROVAL
THIS PERMIT DOES NOT BECOME
VALID UNTIL SIGNED BY THE
BUILDING OFFICIAL OR HIS DEPU-
TY, THE FEES ARE PAID, AND RE-
CEIPT IS ACKNOWLEDGED IN THE
SPACE PROVIDED
By.................................................. ...............
Director's Signature
Date........... .....k--+---------------
DISTRIBUTION OF COPIES
WHITE — File (Bldg. Dept.)
YELLOW — Move Inspector
GREEN — Assessor
GOLDENROD — Police Dept.
PINK — Moving Contractor