640366.pdf-K,-J , HAMS&N
MAILING ADDRESS
CITY
NAME
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NON-RESIDENTIAL
DWELLING
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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
URE (OWNER OR AGENT) DAT7IGNED
Fizz
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Required
ri YES
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PERMIT
NUMBER
1121
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640366
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BUILDING SETBACKS P,
NO'TE: 'TO E&VE LINES
46
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'AM
BUILDING
1
VALUATION
BUILDING PERMIT
2
FEE
PLUMBING
3
PERMIT FEE
HEAT & GAS LINE
4
PERMIT FEE
DEMOLITION
5
PERMIT FEE
6
AMOUNT DUE
ATTIMNTION
Tins PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDIVIONDS
FR U-1107
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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.
DIRECwokvkj �GNATURE
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