M-144-69.pdf7
IMPORTANT! Press Firmly While Writing Application!
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• • Applicant Fill - PERMIT
Building Relocation Permit Inside Heavy Lines NUMBER -
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OW $^NAME
NNW SITE ADDRESS
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MAILI AD RE58
EDMONDS PRE -MOVE
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PERMIT NOFIRE
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MIT NO.
FOR WORK
MOVING CONTRACTOR
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MOVE CONTRACTOR'S INSURANCE COVERAGE
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STREET ADDRESS
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NAME OF SURETY
PROVIDING P.L. &
P.D. COVERAGE
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CI &ZONE TEL, NO. STREET ADDR�6S
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C6NTRACTOR'8
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STATE STACITY BUSINESSl� �
LICENSE NO. ^ O' l LICENSE NO. �/l,�t•,-Y 60'
VALID INSURANCE POLICY
SITE DESCRIPTION ?
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ADDRESS OF PRESENT BUILDING SITE
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BUILDING DESCRIPTION
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Legal Description of Present Bldg. Site — (Show below or attach four copies)
DESCRIB BASIC CONSTRUCTION & PRESENT USE OF BUILDING:
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OVERALL LENGTH OF BUILDING: - FT.
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ADDRESS OF NEW BUILDING SITE
HEIGHT AS LOADED
WIDTH AS LOADED BLDG. AREA
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FT.
c7. FT. $Q. FT.
Legal Description of New Bldg. Site — (Show below or attach f ur copies)
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POLICE DEPT. APPROVAL OF MOVING ROUTE
DATE'J
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BY: ,
/...........................
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Time to Commence Moving: ..............................
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MOVING ROUTE
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Time to Finish Moving:............................................................. .......
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FIRE DEPARTMENTNTCLEARANCE OF ROUTING
DATE
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ENGINEERING CLEARANCE
DATE
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CLEARED BY:
PowerCompany ❑_ .........._...._................. ........... .......... _............... ...........
REL CATION - RECEIPT NO.;
PERMIT
FEE /
Telephone Company ❑................................................. .......... .............. ..-.
$
NAME OF OWNER OF PRESENT BUILDING BITE
ATTENTION:
PERMIT APPROVAL
THIS PERMIT
THIS PERMIT DOES NOT BECOME
MAIL OR HOME ADDRESS
AUTHORIZES
VALID UNTIL SIGNED BY THE
ONLY THE
BUILDING OFFICIAL OR HIS DEPU-
I herebyacknowledge that I have read this application; that
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RELOCATION
TY, THE FEES ARE PAID, AND RE_
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
BUILDING
of these. I agree to comply with city and state laws regulating
building relocation; and in doing this work, no person will be
NOTED
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.relatin
employed in violation of the Labor Code, State of Washington
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to Workmen's Come sat n Insurance.
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Signature of Owner, / /q/ /7
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BUILDING
Contractor, Or �j ,f
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Authorized A eat ...... .-.--- �`'. �x ��L..............
INSPECTION
DEPARTMENT
Date .........
SIgner's '3 Phone 3
Address 1-.....�.:.....'...'.. J'
CITY O
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DISTRIBUTION OF COPIES
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............................................ - .... .-...: ............................-......---
PR 6-11o7
WHITE —File (Bldg. Dept.)
Date........------••-
YELLOW — MoveInspector
GREEN Assessor
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GOLDENROD —Police Dept.
PINK — Moving Contractor
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