650231.pdfPLAN FILE NUMBER
PERMIT
6 5,1--)2'- 3 1
Applicant Fill
NUMBER
Building Permit Application lInside Heavy Lines
NAME (OR NAMIF OF BUSINESS) JOB ADDRESS /")v
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SIDE
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NAME BUI
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VARIANCE NUMBER
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TELEPHONE NUMBER
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TELEPHONE NUMB
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REMARKS
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TYPE CONNECTION
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WORK TO BE ONE
NEW I I I DEMOLISH
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ALTER IM RESIDENTIAL NUMBEIR OF
DWELLING
MPAIR F-1 NON-RESIDENTIAL I UNITS
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-
1,tlng 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 Workman's Compensation Insurance.
NOTE: PERMIT LIMIT ONE YEAR
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PLOT
3 U..11 1y; 1?�
FILE
[3 YES [3 NO
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BUILDING
I
VALUATION
BUILDING PERMIT
2
FEE
PLUMBING
3
PERMIT FEE
HEAT & GAS LINE
4
PERMIT FEE
DEMOLITION
5
1 ERMIT FEE
61 AMOUNT DUE
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ATTENTION APPLICATION APPROVAL
TI I This application is not a permit until
AUTHORIZES signed by the Director of Building Inspec-
ONLY THE
WORK NOTED tion, or his deputy; and fees are paid, and
I receipt Is aclmowledged in space provided.
INSPECTION oil
DEPARTMENT
CITY OF
EDMONDS
PR 6-1107
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