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Applicant Fill )� (/ n l� PERMIT i( I ( 18
Building Relocation Permit Inside Heavy Lines rJ NUMBER 1Vl -f
OWNER'S NAME NEW SITE ADDROS
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MOVE CONTRACTOR'S INSURANCE COVERAGE
ADDRESS
NAME OF SURETY
PROVIDING P.L. &
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/V• CITY & ZONE J �'(• TEL. NO,
CONTRACTOR'S I CITY BUSINESS
STATE
LICENSE NO.- ;- 'S-`l".' l '- 5 S &:'� LICENSE NO.
SITE DESCRIPTION
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BUILDING DESCRIPTION
DESCRIBE BASICPONSTRUCTION & PRESENT USE OF BUILDING:
OVERALL LENGTH OF BUILDING:
FT.(i f r. i
or attach four copies)
POLICE DEPT. APP OVAL OF MOVING ROUTE
By:
Time to Commence Moving: ..........................................
Time to Finish Moving: ..................................................
CLEARED BY:
PowerCompany ❑........................................................................................
TelephoneCompany ❑................................................................................
NAME t � OWNEE OF PRESENT BUILDING SITE
I l J d—a- l V I tYf-OC —— --
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 Insurance.
Signature of Owner, .� 7 J
Contractor, or - ^—"`
E L �. .� Z
Authorized Agent( :R :...... <.?.........xr......... '::::.-/.....
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Address gn �•.��...•-,........!...._....................NNo. .r..:.......".
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City � : " T....\............... ........... ................
.
Date............................................................
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ATTENTION:
THIS PERMIT
AUTHORIZES
ONLY THE
RELOCATION
OF THE
BUILDING
NOTED
BUILDING
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PR 0-1107
®I
SQ. FT.
DATE
E ` D TE
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f AU/Ca
D RECEIPT
ETNO.,. / ("%
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.............................or;---........_...'e............_....
Director's Signature
Date........1... _...�...... ... .........
DISTRIBUTION OF COPIES.
WHITE — File (Bldg. Dept.)
YELLOW — Move Inspector
GREEN — Assessor
GOLDENROD — Police Dept.
PINK — Moving Contractor