640126.pdfit Application
PLAN
Applicant Fill
FILE -NUMBER
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BUILDING
PERMIT
Mo 1 2t,
side Heavy Lines
NUMBER
BUSINESS) JOB
ADDRESS
rq
YARD
SET BACK
PEAR YARD
SIDE
e-tf IAJO
TA —PHONE NUMBER
VACANT SITE
USE. ZOUF
MAP NUMBER
YES C14,40
BUILDING AREA
LOT A
VARIA14UN NUMBER
J
HEIGHT
ALL BUILDING SETBACKS
NOTE: TO EAVE LINES
TELEPHONE NUMBER
REMARKS
Encroachment Permit PERMIT NUMBER STREET GRADE CHECKI
Required
I I
Z
F1 YES
TELEPHONE NUMBER
METER SIZE SERVICE SIZE CLEARANCE CHECKED BY
REMARKS
,CENSE NUMBER
CITY LI UENSF NUMBER
BLOCK TRAC!r,/A�� a�
NEW
DEMOLISH
IES
NUMBER OF STORIES
ADD
QALTER
RESIDENTIAL
NUMBER OF
F�
REPAIR
NON-RESIDENTIAL I
DWELLING
UNITS
I hereby acknowledge that I have read this application; that the In-
formation given to correct; and that I am the owner, or the duly author-
ized agent of the owner. I agree to comply with city and state laws regu-
lating construction; and In doing the work authorized thereby, no person
will be employed In violation of the Labor Code of the State of Washington
relating to Workmen's Compensation Insurance.
NOTE: PERMIT LIMIT ONE YEAR
PLAN CHECK &
FILE
'C' /�(
[] YES 13 NO
[:] YES [] NO
BUILDING
VALUATION
BUILDING PERMIT
2
FEE
PLUMBING
3
PERMIT FEE
HEAT & GAS LINE
4
PERMIT FEE
_51
DEMOLITION
PERMIT FEE
6 1 AMOUNT DUE
ATTENTION I APPLICATION APPROVAL
THIS PERMIT This application is not a permit until
AUTHORIZES signed by the Director of Building Inspec-
ONLY THE
WORK NOTED tion, or his deputy; and fees are paid, and
receipt is acknowledged In spac"rovided.
INSPECTION DIRECTOR'S SIGNAT RE
DEPARTMENT
Dirk van Dyk, Bldg._01U7L_/_
CITY OF DATE
EDIVIONDS
Pit 0-1107 _�_/Zl Z &
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