640242.pdf-1 —
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NEW
DEMOLISH
ADD
ALTER
F�71
RESIDENTIAL
NUMBER OF
F�
REPAIR
F� NON-RESIDENTIAL
DWELLING
UNITS
I hereby acknowledge that I have read this application; that the in-
formation given Is 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
SIGNATURE (OWNER OR -AGENT DATE SIGNED
PLGTPZkN tHECIC-Ir APPROVED
FILE
[I YES
t
*=6
BUILDING
1
VALUATION
BUILDING PERMIT
2
FEE
PLUM13ING
3
PERMIT FEE
BEAT & GAS LINE
4
PERMIT FEE
DEMOLITION
5
PERMIT FEE
6
AMOUNT DUE
ATTENTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDIVIONDS
PR 6-1107
7
0 YES [j No
Polm
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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 acknowledged In space provided.
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11
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