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Building P
NAME k0HjNA
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AD
,I 14UTY
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NAME
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I ADDRESS
NEW
EjADD
� ALTER
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i 1 REPAIR
Applicant Fill
Application Ittside Heavy Lines
I EBB)
Ie l�ewi �rztV'�
ITELEPHONE NUMBEN.
'PR I- ?)
DEMOLISH
RESIDENTIAL NUMBER OF
DWELLING
NON-RESIDENTIAL UNITS
I hereby acknowledge that I have read this application; that the in-
formation given is correct: End 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
FILE
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PLAN FILE NUMBER BUILDING
PERMIT
NUMBER 640215
]OB ADDREBB
1
BIDE YARD i ET ACK REAR YARD
USE ZONE MAP NUMBER VACANT SITE
0 YES 0 NO k7
BUILDING AREA LOT AREA (VARIANCE NUMBER 1
`4
HEIGHT ,
ALL BUILDING SETBAOHB
NOTE: TO EAVE LINER
REMARKS
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Encroachment Petmlt PERMIT NUMBER STREET GRADE CHECK k!
Required
YES NO
METER SIZE I SERVICE SIZE CLEARANCE I CHECKED BY '
REMARKS �7It
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TYPE CONNECTION I VERIFIED BY '� ' t '
PERC. 'TEST PERMIT NUMBER `
1 �
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ZONE (TYPE OF CONSTRUCTION STREET
0 YES 0 No .I. �T I
SPECIAL INSPECTOR RERUIRED OCCUPANCY GROUP ff
0 YES NO
PLAN CHECKED BY I J.
1
NO. OF BLOCS. PER/BLOC. TOTAL FEZ
BUILDING `,
O
I VALUATION ;60acyV 1
SUILDIIIG PERMIT'i,
B Z FEE
PLUMBING
3 PERMIT FEE 1 i,
HEAT & GAS LINE
d PERMIT FEE
DEMOLITION • J
B PERMIT FEE - ' 11.
B AMOUNT DUE 49-V - 1 1
A'.MENTION APPLICATION APPROVAL
THIS PERMIT This application is not a permit until
AUTHORIZES signed by the Director of Building Inspec
ONLY THE tion, or his de ut and fees are aid and
WORK NOTED p y' p '
receipt is aclmowledged in space provided.
I ILL
INSPECTION DIRECTOR'S SIGNATURE
DEPARTMENT Dirk van Dyk, Bldg. Official
EDMONDS DwTE
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