640403.pdfI �.Skppllcant FIR
Building Permit Application 'de Heavy Lines
NAME (OR NAME OF BUSINESS)
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MAILING ADDRESS
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CITY TELEPHONE NUMBER
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NAME
ADDRESS
CITY TELEPHONE: NUMBER
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,DDRESS
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UTY TELEPHONE NUMj
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IN
WORK
NEW DEMOLISH
ADD 1 .2,
ALTER N BE
REPAIR I [IrRESIDENTIAL 3 UM LL R OF
3WE NG
NON-RESIDENTIAL I UNITS
PROPOSED USE
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 construcUon; 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
R AGEN
UGI.YLTU _E (OWNER OR DATE SIGNE
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FILE
PLAN FILE NUMBER BUILDING
PERMIT 640403
NUMBER
JOB ADDRESS 4 112
SIDE YARD SET BA, REAR YARD/
USE ZONE xAr NUMBER VACANT SITE
YES NO
BUILDING AREA LOT AREA VARIANCE NUMBER
Hl--' GHT /_2, fl
L UILDING SETBACKS
N O/TE: TO E'AVE LINES
Enctomehm.
Required
n YES
El YES
NO
BUILDING
1
VALUATION
BUILDING PERMIT
2
FEE
PLUMBING
3
PERMIT FEE
HEAT & GAS LINE
4
PERMIT FEE
DEMOLITION
5
PERMIT FEE
a
AMOUNT DUE
ATTENTION
Tius rERMT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDIVIONDS
PR 6-1107
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6
Z
W
[] YES [3 go
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10. OF OLD09. PERIBLOG. TOTAL FEE
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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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