640214.pdf'.fLA 4A M.
Applicant
Permit Application I Inside Hear
L�exl7xl_F A/A/ 1jW_9_
NAME
-5 .9 Ir
CITY TELEPHON
NAM
ADDRESS
CITY TELEPHOR
STATE LICENSE NUMBER CITY LICE]
LOT BLOCK
Z
0
W
TOON DONE
NEW
DEMOLISH
NUMBER OF
El ADD
I
F-1 ALTER
RESIDENTIAL
NUMBER OF
F-1
REPAIR
M
NC
DWELLING
UNITS
Required
n YES
0 YES [j NO
1
VALUATION
fe
2
BUILDING PERMIT
FEE
ES
3
PLUMBING
PERMIT FEE
4
HEAT & GAS LINE
PERMIT FEE
IBUILDING
5
DEMOLITION
PERMIT FEE
6
1AMOUNT DUE
I hereby acknowledge that I have read this application; that the In-
formation given In correct: and that I am the owner, or the duly author. ATTENTION
Ized agent of the owner. I agree to comply with city and state laws regu- TIUS PERMIT
lating construction; and In doing the work authorized thereby, no person AUTHORIZES
will be employed In violation of the Labor Code of the Stata of Washington ONLY THE
relating to Workmen's Compensation Insurance. WORK NOTED
NOTE: PERMIT LIMIT ONE YEAR
0 R ENT) DATE 8 INSPECTION
DEPARTME24T
4�' J
CITY OF
LOT PLAN CHECK & A70VED EDMONDS
PR 0-1107
FILE
;�WWT 640214.
NUMBER
-7-
YES [] NO
NUMBER
,OT AREA VARIANCE
ALL BUILDING SETBACKS
NOTE: TO EAVE LINEB
6
Z
W
0 YES [3 NO
.OGS. PERJULD0. TOTAL rZK
M
I --- j.=5_,oW
APPLICATION APPROVAL
This application is not a permit until
signed by the Director of Building Inspec-
tion, or his deputy; and fees are paid, and
receipt is aclmowleqWd in space provided.
DIRECYOR'S P!IGNATr
,Q W ffil
Dirk �an D�g fficial
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