640437.pdfPermit
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_PH'NE NUMBER
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MAP NUMBER
1
VACANT ULTN
1 0 YES [3 NO
0
NAME
BUILDING AREA
LOT AREA
VARIANCE NUMBER
ADDRESS
HEIGHT
ALL BUILDING SETBACKS
I NOTE: TO EAVE LINES
CITY
TELEPHONE NUMBER
REMA
NAME
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Encroachment Permit PERMIT NUMBER SwRmbrl- OHJ DE CHECK
Required
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CITY
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TELEPHONE NUMBER
METER SIZE I SERVICE SIZE CLEARANCE CHECKED BY
REMARKS
STATE LICENSE NUMBER
CITY LICENSE NUMBER
LOT BLOCK TRACT
P-C)S e
TYPE CONNECTION VERIFIED BY
PERC. TEST PERMIT NUMBER
FIRE FQNE TYPE OF COYNPUCTION STREET IMPROVED
Z
MITES 0 NO
SPECIAL INSPECTOR REQUIRED OCCUPANCY GROUP
YES t1`NO
PLAN CHECKED BY
Z
0
WORK TO BE DONE
NO. OF BLOGS.
PERIBLOO.
TOTAL FCC
1
BUILDING
VALUATION
590 0
to
2
BUILDING PERMIT
FEE
ro
EW
DEMOLISH
NUMBER OF STORIE
3
PLUMBING
PERMIT FEE
4
HEAT & GAS LINE
PERMIT FEE
ALTER
REPAIR
RESIDENTIAL
1 Q NON-RESIDENTIAL
N OF
D =LLING
UNITS
1
5
DEMOLITION
PERMIT FEE
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6
AMOUNT DUE
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I hereby acknowledge that I have read this application; that the In-
formation given Is correct; and that I arn the owner, or the duly author-
ATTENTION
APPLICATION APPROVAL
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 he employed In violatlon of the Labor Code of the State of Washington
relating to Workmen's Compensation Insurance.
NOTE: PERMIT LIMIT ONE YEAR
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
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.
INSPECTION
DEPARTMENT
CITY OF
EDIVIONDS
PR 6-1107
SIGNATURE (OWNER OR AGENT)
DATE SIGN D
DI IONATURE
-eele!?-e-c
DATE
PLOT PLAN CHECK & APPROVED
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