640311.pdff
sTED ON KROLL MAP NO.: BUILDING
BUILDING DEPARTMENT Applicant Fill PERMIT
NUMBER 660031
Inside Heavy Lines JOB ADDRE1313
PERMIT APPLICATION I
NAME (01
CITY
ADD
CITY
TE-LEPHONE NUM
8
ple—x—,f3do
STATE LICENSE NUMBER
CITY LICENS N(
Legal Description of Property (Show Below or Attach Four Cop
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WORK TO BE DONE
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SIGN
NUMBOR 0
NDWD I
DEMOLISH
FENCE
oft
�A LT �M
RESIDENTIAL
NUMBER OF
IF
I DWELLING
REPAIR
I NON-RESIDENTIAL
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 constmetIon; 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.
(Except Demolitions which shall
NOTE: Permit Limit One Year be completed in ninety days.)
UGNATURE (OWI#f�R OR AGENT) DATE SIGNED
v
NOTE: Applicant Subject to Plan Check Fee
IETBACK I STREET SETBACK
0 YES
I I VALUATION
BUILDING PERMIT
2
FEE
PLUMBING
3
PERMIT FEE
HEAT & GAS LINE
PERMIT FEE
SIGN PERMIT
5
FEE
DEMOLITION
6
PERMIT FEE
PLAN CHECK
7
FEE
8 1 AMOUNT DUE
ATTENTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PR 6-1107
VACANT SITE
E3 YES 0 0
VARIANCE NUMBER
0 YES 0 NO
L9
6
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APPLICATION APPROVAL
This application is not a permit unti
signed by the Director of Building Inspec
tion, or his deputy; and fees are paid, an(
receipt Is aelmowledged in space provided
DIRECTOR'S SIGNATURE
DATE
This remit covers work to be done on Private property ONLY.
Any construction on the public domain (curbs, sidewalks, drivnvays,
marquees, etc.) will require separate permission. I FILE
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Final