M-136-67.pdf✓ -IMPORTANT!- Press Firmly While Writing Application!
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• ApplIP�A'' PERMIT i► ( / 7
.Building Relocation Permit II1Sltic W NUMBER
OWNER'S NAME NEW SITE ADDRESS
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MAILING DRESS
EDMONDS PRE-MOVEION
PERMINSPEIT NO. r3CITY & ZONETELr ?P�FIRE BLDG. PERMIT NO.
�J 12 3 FOR WORK
L. V1 A( `. J, !�� 'LONE AT NEW SITE
MOVING CONTRAC OR tCMOVE CONTRACTOR'S INSURANCE COVERAGE
,`T t / I ( ' " (- NAME OF SURETY �STREET A SS PROVIDING P.L. & y /P.D. COVERAGE JrVl �/ � (?r �1F 171!/V (�"-"� 1��''
CITY &ZONE TEL. NO.
CONTRACTOR'S CITY BUSINESS
STATE LICENSE NO.
LICENSE NO. -2c�
SITE DESCRIPTION
ADDRESS OF PRESENT BUILDING SITE
Legal Description of Present BBlldyg. • •Ite —/ (Show below or attach four cop
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VALID INSURANCE POLICY CHECKED BY: DATA:
BUILDING DESCRIPTION
DESCRIBE BASIC CONSTRUCTION & PRESENT USE OF BUILDING:
OVERALL LENGTH OF BUILDING: 3 a FT -
ADDRESS OF NEW BUILDING SITE
HEIGHT AS LOADED
WIDTH AS LOADED I BLDG. AREA
T.
•5S '- FT. SQ. FT.
Legal Description of New Bldg. Site — (Show below or attach four wples)
POLIC DF T. APPR VAL OF MOV NG ROUTE
DATE
T
I
me to Commence Moving: .. . - f.'•l,}� f•I`
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MOVING ROUTE
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Time to Finish Moving: .... . ...........................
FIRED PARTMENT CLEARANCE OF ROUTING
DATE
r 1 fc C,L 0 O
I
�C I Ct �C�}'Y�M.L y •I� l 'L�h,
v�Y1
•- „ "
By.
ENG ERING CLEARANCE
DATE
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CLEARED BY:
PowerCompany _.
RELOCATION
PERMIT
I RECEIPT NO.
❑................................. ....................................................
FEE $
Telephone Company ❑................................................................................
NAME OF OWNER OF PAR-E.SENT BUILDING SITE
Il
ATTENTION:
PERMIT APPROVAL
-l.�l --b , _1j 6 of 1 0 A(
THIS PERMIT
THIS PERMIT DOES NOT BECOME
MAIL OR HOME ADDRESS
AUTHORIZES
VALID UNTIL SIGNED BY THE
ONLY THE
BUILDING OFFICIAL OR HIS DEPU-
TY, THE FEES ARE PAID, AND RE -
I hereby acknowledge that I have read this application; that
RELOCATION
CEIPT IS ACKNOWLEDGED IN THE
the information given is correct; and that I am the owner, a
OF THE
SPACE PROVIDED
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
BUILDING
NOTED
r
Labor Code, State of Washington
' �,,,,•„••-„•„•„-,•••---•
employed in violation of the
By .............
relating to Workmen's Compensation Insurance.
Director's signature
Signature of Owner, •�
Contractor, Or-•��''� -
BUILDING
IxsPECTION
DEPARTMENT
77
Authorized Agent...........yt..:...... c:f...: -.!_ ... -.- ._fie.....:..-..
�y c:. vtril'
Signer's U ) Phone -
�•. �`
CITY OF
Date
R
Address ..-�:7 -•••••-•
EDMONDS
DISTRIBUTION OF COPIES
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City ...L ,�.� `✓.:. . ......:..........................................
PR o-no;
WHITE — File (Bldg. Dept.)
YELLOW — Move Inspector
Date.--.-.-.�.-.- 7....................................................................
�,
GREEN — Assessor
GOLDENROD — Police Dept.
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PINK — Moving Contractor