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NAME
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LEPHONE NUMBER
NAME
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CITY TELEPHONE NUMBER
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ALTER
REPAIR
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DEMOLISH
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RESIDENTIAL NUMBER OF
DWELLING
NON-RESIDENTIAL I UNITS At&
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
PLOT
FILE
4�0.
0 YES NO
BUILDING AREA LOT AREA VARIANCE —NUMBER
HEIGHT NOTE: ALL BUILDING SETBACKS N
TO EAVE LINES
REMARKS
Encroachment Permit PERMIT NUMBER STREET GRADE CHECKI's
Required
F 0 NO
_1 YES
METER SIZE I SERVICE SIZE CLEARA NCE CHECKED By
-E—MARKS
-rxk,E CONNECTION VERIFIED BY
PERC. TEST PERMIT NUMBER
FIRE ZONE TYPE OF CO MON B-TRF T IMPROVED
YES No
SPECIAL INSPECTOR REQUIRED OCCUPANCY GROUP
[3 YES NO
PLAN CHECKED BY
NO. OF BLOGG. PERIBLDG. TOTAL FEE
BUILDING 0
I VALUATION
L'I, ge
BUILDING PERMIT
2 FEE
PLUMBING
3 PERMIT FEE
HEAT & GAS LINE
PERMIT FEE
DEMOLITION
5 PERMIT FEE
6 AMOUNT DUE
ATTENTION APPLICATION APPROV
THIS PERMIT This application Is not a permit until
AUTHORIZES
ONLY THE signed by the Director of Building Inspec-
wORIC NOTED tion, or his deputy; and fees are paid, and
receipt is acknowledged in jpace provided.
INSPECTION SIGNAT E
DEPARTMENT Dj*- Jd2
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Idg. official
CITY OF
DATE
EDAIONDS
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PR 0-1107
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