M-3-85.pdfIMPORTANT! Press Firmly While Writing Application!
Applicant rill
Building Rel®aati®n Permit Inside Heavy Lines
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I PERMIT
NUMBER 1VAJ C
OWNDF{,'B-NAND
NEW SITE ADDRE 8 v }�% ��D ,���1 �/` �, .V •f_
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MAIL NG DR.
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E PRE -MOVE
INSPECTION
PERMIT NO.
CITY &ZONE t, TEL NO.
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BLDG. PERMIT NO. /J
I FOR WORK �/
7 /l/ ,�(�t! '
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AT NEW SITE
MOVING CONTRACTOR/�
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MOVE CONTRACTOR'S INSURANCE COVERAGE
NAME OP'SURETY /
PROVIDING P.L. & r / q (
STREET ADDRESS
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P.D. COVERAGE 6/V i ,!
STREET AD RESS ..
CITY & ZONE -
TEL NO.
CITY, ZONE &(STATE-
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STATE ACTORf'19 ri 1/,
CITY BUSINESS
NO.
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LICENSE N(y'1 V�, 'V CJL}
LICENSE
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VALID INSURANCE POLICY CHECKED BY: (DATE
SITE DESCRIPTION
ADDRESS OF PRESENT B ILDING $ITD
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BUILDING DESCRIPTION
Leg111 Description of Present Bldg. Site — (Show below or attach four copies)
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Ai PAC Et
J• � ,_I '. C ;C[. / -�• �i� i
/OFi lB'UILDING:
DD�S/(/CRIBS/y�BASIC Fjp�NASTR. UCTION `& PRESENT USE OF BUILDIJDATE111
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1.,
A k j ,� '�� f
OVERALL LENGTH
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HEIGHT AS LOADED WIDTH AS LOADED BLDG. AREA
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ADDRESS OF NEW BUILDING SITE t--'
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Legal Description of New Ifldg. Site — (Sbply bC10W 0.auach four TIP"'
71 T.Ia DE T. AP ROVAL F MOVING ROUTE I
/YY/ht�,[dtp (T-I �_j � l .` 7 1�i ,rL �
x, f'tl. 1 CrW -L.t /4� J,/•/ • Time to Commence Moving: ....!......_�L'_!.1/ �...................... C+
,MOVING
ROUTE
RO'UTE• l/Time to Finish Moving: ...................... .......
pi111J�i,p FIRE DEPARTMENT CLEARANCE OF ROUTING ATE} c
I�t1 se. 7� ,lv�,
GINE RING CLEARANCE DATE
CLEARED BY: N % ,�'♦� RECEIPT NO.
PowerCompany ❑........................................................................................ PERMIT ! j i V� Z
FEE $
TelephoneCompany Cl ................................................................................
NA�iME O`F�OWNE t OF PREEB NT BnUIfLDING SITE ATTENTION: PERMIT APPROVAL
` A�AI I THIS PERMIT THIS PERMIT DOES NOT BECOME
MAIL OR HOME /y 7 AUTHORIZES VALID UNTIL SIGNED BY THE
t / / BUILDING OFFICIAL OR HIS DEPU-
ONLY THE 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 BUILDING
of these. I agree to comply with city and state laws regulating NOTED
building relocation; and in doing this work, no person will be
employed in violation of the Labor Code, State of Washington By ..... .....................
relating to Workmen's Compensation Insurance. Director's Signature
Signature of Owner, ! [ BUILDING
Contractor, Or .0 _, fxsPRTM N
Authorized Agent ---=----l/ nEPARTntET Date � -a..... .
Signer' ^ /L/ J /N�.�.Pf %/ Phone Q/t�c!`J CITY Or
Addre J- '•'• l.C. J.......- No...1... 1..CC.. U- (./. EDMONDS
� DISTRIBUTION OF COPIES
City .....1� t� 1�.Y 1..`....i�l..fV........tl�v..�.�...... PR a -Tier WHITE — File (Bldg. Dept.)
YELLOW.— Move Inspector
GREEN — Assessor
Date ........ !..>1.............................................................. GOLDENROD — Police Dept.
PINK — Moving Contractor