650161.pdfN [] YES
WORK TO HE DQNE
BUILDING
VALUATION
BUILDING PERMIT
FEE
NEW
ADD
DEMOLISH
)F on�
N MBER OF STWO J2
3
PLUMBING
PERMIT FEE
4
BEAT & GAS LINE
PERMIT I=
ALTER
REPAIR
RESIDENTLAL
NON-RESIDENTIAL
)p
BER OF
NUMB
DWELLING
UNITS
1
5
51
DEMOLITION
PERMIT FEE
61 AMOUNT DUE
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- ATTENTION
lzed agent of the owner. I ease to comply with city and state laws resu- Tills PERMIT
luting construction; and In doing the work authorized thereby, no person AUTHORIZES
will be employed In violation of the Labor Code of the State of Washington ONLY THE
relating to Workmazes Compensation Insurance. WORK NOTED
NOTE: PERMIT LIMIT ONE YEAR
3IGNATURE (OWNER OR AGENT) VATM lu INSPECTION
DEPARTMENT
CITY OF
pHEC &,APPROVW EDHO"S
PR 6.1107
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FILE
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PERMITMR,
)NSTRU02SON STREETTUPOVED
Cl YES [3 No
MED
GROUP
JOCCUPANCY
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PERIBLDO.
TOTAL FRE
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APPLICATION APPROVAL
This application is not a pernilt. until
signed by the Director of Building Inspec-
tionor ul- d A 4- n4A
A
es
receipt is acknowledged in space prZvided.
DIRECTOR'S SIGNATURE
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