M-5-77.pdfIMPORTANT! Press Firmly
Applicant Fill
Building Relocation Permit I Inside Heavy Lines
OWNER'S NAME
MAILING ADDRESS
;�o .3 o`/
CITY& ZONE A TEL. NO.
Welu^it6 ) 1!917%4 U,% t
MOVING CONTRACTOR
STREET ADD nSS
CITY & ZONE I TEL. NO.
CONTRACT R'8STATEl '�`� �-� CITY BUSINESS
LICENSE NO.<<•,.J -2 ?'i� LICENSE NO.
SITE DESCRIPTION
ADDRESS OF PRESE711111
BUILDING SITE
r3�.51 �%uf S7
Legal Description of Present Bldg. Site — (Show below or attach four copies)
— (Snow below or
I/1//x /i! a f '5 /, 4 �f A vr3,
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Nbii( uZ�r# Application!
PERMIT "� �( -^ r r'J
NUMBER ��/�/ I
NEW SITE ADDRESS
A
EDMONDS PRE -MOVE
INSPECTION
PERMIT NO.
G ;.
w
FIRE
I 2 3 I
BLDG. PERMIT NO.
FOR WORK
ZONE
AT NEW SITE
.4
MOVE CONTRACTOR'S INSURANCE OVE E
RAP
NAME OF SURETY t�
PROVIDING P.L. & I X1 Cl
P.D. COVERAGE
STREET ADDRESS
TY, ZONE & STATE
'.
VpA,LfIDD I/NSUR�A�N(JC�EPOLIPY CHECKED BT[ DATE
BUILDIZ DESCRIPTION
DESCRIBE BASIC CONSTRUCTION & PRES NT USE OF BUILDING:
i /`���7 P / �'S i' G ,'� r C
OVERALL LENGTH OF BUILDING: FT.
]EIGHT AS LOADED
WIDTH AS LOADED
BLDG. AREA
L
I
FT.
FT.
SQ. FT.
POLICE DEPT, APPROVA OF NG R TE
DATE
(
W
O
c
�+
;
Time to Commence btovtng: ..... .OQ ..../..C..I................
.
Time to Finish Moving: .... ...... ...... .. ....................
j
FIRE DEPARTMENT CLEARANCE OF OUTING
DATE
E GINEE NG CLEARANCE
DATE
c
G
,
W
CLEARED BY:
RELOCATION RECEIPO.
Power Company ❑........................................................................................ FEE
!.n o "i
Telephone Company ❑................................................................................ S O(
NAME OF OWNER OF PRESENT BUILDING SITE ATTENTION: PERMIT APPROVAL
MAIL OR HOME ADDRESS THIS PERMIT THIS PERMIT DOES NOT BECOME
AUTHORIZES VALID UNTIL SIGNED BY THE
ONLY THE BUILDING OFFICIAL OR HIS DEPU-
TY, �.
RE -
I herebyacknowledge that I have read this application; that RELOCATION THE FEES ARE PAID, AND HE
g PP 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, 137 `- /� BUILDING
Contractor, or �J�_ il��- txsrEcrlox %ly
Authorized Agent ....-..t' .........:....... ......................._ f...--------•------. DEPARTMENT Date t V � � i
Signer's (, / j�/ Phone / !'
Address/?...... :f «.. .... ` ... .e.........No.. 4:. ._ 1.... CITY D
EDMONDS
rt DISTRIBUTION OF COPIES
City G.... _...F......._...j........t................................................ PR a-tto: WHITE — File (Bldg. Dept.) +
/ YELLOW — Move Inspector.:':
Date ....... - ! / 4 Z1I 7 GREEN — Assessor
..... .-- ......................... ..
'"' "'7` " GOLDENROD —Police Dept.
aoffamagm PINK — Moving Contractor (.