650051.pdf130
PLAN FILE NUMBER 13UL�I�u btDUUD I
Building - Permit Application ines
PERMIT
NUMBE - R
NAME (olt rjAjaju OF BUSINESS)
JOB ADDRESS
L__j
"IX
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I
MAILING ADDRIGHS
A RD
AR YARD
R Y
SIDE YARD SET BACK RE
/y// 0 Z
!ER
B
BITE
ITE
CITY
NUMBER VACANT
BE ZONE MAP VAM�T
; - 1 (1, j
/)//J, A-�. e,
Y _B 0 No
0 F
13 YES 0 No 0
1/rA111,0 1Y
V , ARL,_ NCE 14UMBER
NU-ILDING AREA LOT AREA VARIAN E NUMBER
NAME
ADDRESS
ETBACYS
ALL BUILDING SETBACKS
NOTE:
TO EAVE LINES
CITY TELEPHONE UMBER
NAME
A) (0) A- (!A
ADD SS
Encroachment Permit PERMIT N UMBER STREET GRADE CHECKjdZ
Required rl NO
ri YES
CITY TE�M034E NU
TER SIZE SERVICE SIZE ARANCE CHECKED BY
STATE LICErqbW VU&IBER CITY LIcENuz L41 'MBER
RE a
TYPE CONNECTION VERIFIED BY
1
;4
PERC. TEST I PERMIT NTJM13ER
ZONE TYPE OF CONSTRUCTION STREET IMPROVED
YES NO
Z
SPECIAL INSPECTOR REQUIRED
OCCUPANCY GROUP
YES 0 NO
PLAN CHECKED BY
Id
Z
NOv OF BLOGS*
PKRIOLDO. TOTAL F99
BUILDING
VALUATION
BUILDING PEIUUT
2
FEE
EjNEW DEMOLISH
NUMBER OF STORIE
PLUMBING
ADD
3
PERMIT FEE
HEAT & GAS LINE
ALTER RESIDENTIAL
Fq
NUMBER OF
4
PERMIT FEE
DEMOLITION
El
DWELLING
UNITS
REPAIRI NON-RESIDENTIAL
5
PERMIT FEE
6
AMOUNT DUE
I hereby acknowledge that I have read this application; that the in- NTION
ATTE
APPLICATION APPROVAL
formation given in 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- TRIS PER1510IT
This application is not a permit until
lating construction; and In doing the work authorized thereby. no person AUTHOMZES
signed by the Director of Building Inspec-
will be employed in violation Of the Labor Code of the State of Washington ONLY TKE
tion, or his deputy; and fees are paid, and
relating to Workmen's Compensation Insurance. WORK NOTED
receipt Is aelmowledged in space provided.
NOTE: PERMIT LIMIT ONE YEAR
,yRPCTOR'S 13IPNATURE
f
INSPECTION
SIGNATURE R AGENT) DA F G
DEPARTMENT
L CITY OF
DATE
EDMONDS
LOT pLA.N CHECK & APPROVED
PR 0.1107
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