M-129-67.pdfIMPORTANT! Press Firmly W
Applicant rill
Relocation Permit Inside Heavy Lines
I. Iverson
MAILING ADDRESS
17624 Talbot Road
Albert Nielsen
STREET ADDRESS
1315 N. 41st St.
CITY & ZONE TEL. NO.
Seattle, Wn. I Me.2-6338
CONTRACTOR'S I CITY BUSINESS
STATE ,223-02-4157 LICENSE NO.
LICENSE NO
SITE DESCRIPTION
— (snow below or
and 220th S.W., Mtlk. Terr., Wn.
don of New Itid¢. Site — (Show below or attach four Wpf
Talbot Road to 76th W., south to
��,n+i, G_W_ — nnrnss 220th S.W. to
Power Company O .....
Telephone Company
NAME OF OWNER OF PRESENT BUILDING SITE
I. Iverson
MAIL OR HOME ADDRESS
17624 Talbot Road
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 Compe s io Insurance.
Signature of Owner,
Contractor, or
Authorized A gen - .............
y....................................
Signer's % i%- ! ( / ,liA;hone n �33c
Address /.::.�.../.......�........J........................ No. �. �i.—:...............
City ....1-.L�:
C '
Date........ ...............•�----•-----•-.... ... ......... -.................................. -_.
Applicationt
PERMIT i{
NUMBER i�/A l "✓ , l(/ /
68th and 220th S.W., Mtlk. Terr., Wn._
EDMONDS PRE -MOVE
INSPECTION
PERMIT NO.
FIRE BLDG. PERMIT NO.
1 2 3 FOR WORK
ZONE AT NEW SITE
MOVE CONTRACTOR'S INSURANCE COVERAGE
NAME OF SURETY
PROVIDING P.L. &
P,D. COVERAGE Firemens fund of America
Seattle, Wn.
VALID INSURANCE POLICY CHECKED BY: DATE
A. Ellin I 9-19-67
BUILDING DESCRIPTION
DESCRIBE BASIC CONSTRUCTION & PRESENT USE OF BUILDING:
OVERALL LENGTIi OF BUILDING: 32 FT.
19 IT.
I FT.
I SQ. FT.
POLICE DEPT. APPROVAL OF ROfJTE DAT
i
W �
U
Moving: .- �J f a' f
:
Time to Commence
g......................................
.7 i
-;
Time to Finish Moving: ................ .1..r....e' ..�...Y.....¢.:...1.................
FIRE DEPARTMENT CLEARANCE OF ROUTING DATE !
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13
e
ENGINEERING CIAARANCE
DATE e i
t
ZIP J-4
RELOCATION
PERMIT
RECEIPT NO.
v
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o
ATTENTION:
PERMIT APPROVAL is
THIS PERMIT
THIS PERMIT DOES NOT BECOME
AUTHORIZES
VALID UNTIL SIGNED BY THE
ONLY THE
BUILDING OFFICIAL OR HIS DEPU-
TY, THE FEES ARE PAID, AND RE- I
CEIPT IS ACKNOWLEDGED IN THE
OF THE
SPACE PROVIDED l
BUILDING
NOTED
By..................................................' ..........:....
Director's Signature
BUILDING
INSPECTION
`{
C�
DEPARTMENT
Date ` ..............
�� 1
CITY OF
EDMONDS
DISTRIBUTION OF COPIES I
PR 6-II07
WHITE — File (Bldg. Dept.)
YELLOW — Move Inspector
GREEN — Assessor
GOLDENROD — Police Dept.
PINK — Moving Contractor
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