650085 (2).pdf...... . ....
PLAN FILE NUMBER BUILDING
PERM
InRitle llpfLvv NUMBER
Buildina Permit Application Applicant Fill IT 650085
I
/S
Encroachment Perm,
Required
r-i YES I"I NO
[3 YES [3 NO
ETP—NUM13ER VACANT SITE
0 YES NO
,OT AREA VARIANCE NUMBER —
ALL BUILDING SETBACKS
NOTE: TO EAVE LINES
E) YES 13 NO
7 7
r
NO. Or BLDG5.
PERIBLDG.
FEZ
BUILDING
___j0TAL
L
VALUATION
4VC,V
BUILDING PERMIT
36
2
FEE
NUMBER OF STOFRUIES
RNEW
DEMOLISH
—
3
4
PLUMBING
PERMIT FEE
HEAT & GAS LINE
PERMIT FEE
ElADD
1:1 ALTER
(Z,,'.:RESIDENTIAL
NUMBER OF
11 REPAIR
1:1 NON
DWELLING
UNITS
1
—
5
DEMOLITION
PERMIT FEE
-
PROPOSED USE
(I
AMOUNT DUE
1 hereby acknowledge that I have read this application; that the In-
formation given In correct; and that I am 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 be employed In violation of the Labor Code of the State of Washington
relating to Workmens Compensation Insurance.
THIS PERMIT
AUTHoIuZES
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
NOTE: PERMIT LIMIJ�ONE YEAR
receipt is acknowledged in space provided.
SIGNATURE (OWNER OR A NT) DATE NED
6�1t_/4 e-y-71-
PLOT PLAN CHECK & APPROVED
INSPECTION
DEPARTMENT
CITY OF
EDIVIONDS
PR 6-1107
ECTORIS I ATURE
,�ATE
FILE
" I
d I
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