650279.pdfBuilding Permit Application I I n i I d1cP H 'ea,.'y '011 e s
NAME (OR NAME UWBUSINN") Jol
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MAILIN G ADDRESS SH
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CITY TELEPHONE NUMBI!A U
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NAME BU
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WD—DRESS
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CITY
TELEPHONE NUMBER
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STATE) LICENSE NUMBER
CITY LICENSE NUMBER _R
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LOT BLOCK TRACT ,'
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6/j 0 -1-5
WORK TO BE DONE
UMBER OF STORIES
NEW El DEMOLISH
I
F
ADD
ALTER RESIDENTIAL
NUMBER 0 F
REPAIR El NON-RESIDENTIAL
DWELLING
UNITS
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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 end state laws regu-
luting 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 Workmen's Compensation Insurance.
NOTE: PERMIT LIMIT ONE YEAR
SIGNITURE _(OWNDR OR AGENT) DATE SIGNED
LOT PLAN CHECK & A"Ro
7D
'�>' FILE
650279
LN FILE NUMBER BUILDING
PERMIT ir
NUMBER
ADDRESS
IE YAIRD SET BACK R YARD
P.l% ZONE MAP NUMBE VACANT SITE
7
0 YES [1] N 0 0
VARIANCE NUMBER
iEDING AREA LAXX AltNA
JOHN ALL BUILDING SETBACKS
NOTE: TO E&VE LINES
MARKS I
croachment Permit PERMIT NUM33ER STREET UKAIJ� U��j
quired
YES 0 NO
[] YES [] NO
I YES [] NO
Cd
NO. OF 13LOGG.
PZRJ�___
TOTAL FX9
BUILDING
�&qe)
VALUATION
0
2
BUILDING PERMT
FEE
PLUMBING
3
PERMIT FEE
HEAT & GAS LINE
4
PERMIT FEE
DEMOLITION
51
PERMIT FEE
OUNT DUE'
ATTENTION
APPLICATION APPROVAL
TIUS PERMIT
This application is not a permit until
AUTHOIUZES
signed by the Director of Building Inspee-
ONLY THE
tion, or his deputy; and fees are paid, and
WORK NOTED
receipt is acknowledged in space provided.
INSPECTION
DIRECTOR'S SIGNATURE
DEPARTMENT
'�7
CITY OF
DATE-
EDATONDS
Pill, 6-1107
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