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Applicant FIR
I'Building Permit Applicationi Inside Heavy LineE
NAM5 (OR NAME OF BUSINESS)
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MAILING ADDRESS
CITY TELEPHONE NUMBEal.
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NAME
ADDRESS
CITY TELEPHONE NUMBER
NAME
ADDRESS
CITY TELEPHONE NUMBER
STATE LICENSE NUMBER CITY LICENSE NUMBER
LOT BLOCK TRACT
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NUMBE" PERMIT U 650290
NUMBER_
BET BACK REAR YARD
MAP NUMBER VAC SITE
YES NO
V
AREA LOT AREA VARIANCE NUM
04
L BUILDING SETBACKS
NOTE: TO EAVE LINES I
Required
1`1 YES n NO
a
.;a- I -ZU - 4), — I [] YES 13 NO
SPECIAL INSPECTOR REQUIRHD OCCUPANCY GROUP
0 YES a, or I �C-- /
71"
BUILDING
VALUATION
BUILDING PERMIT
2
FEE
NEW
DEMOLISH
NUMBER OF STORIES
PLUMBING
ADD
3
PERMIT FEE
HEAT & GAS LINE
PERMIT FEE
F-1
NUMBEIR OF 4
ALTER
RESIDENTIAL
DWELLING
UNITS
DEMOLITION
REPAIR
NON-RE131DENTIAL
5
PERMIT FEE
PROPOSED USE
6
AMOUNT DUE
I hereby acknowledge that I have read this application; that the in-
ATTENTION
formation given Is correct; and that I am the owner, or the duly author-
lzed agent of the owner. I agree to comply with city and state laws regu-
THIS PERMIT
lating 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 Workrnen's Compensation ins
WORK NOTED
NOTE: PERMIT LIMIT ONE E�R
SIGNA2RE RLIJ, AG NT) DA`rk; 3#iUNED /
INSPECTION
JIUW
DEPARTMENT
CITY OF
-pLA
EDMONDS
7. ,N CHECK & APPRO,
I
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PR 6-1101
FILE
OF
I
7ej 1 1-19 01
APPLICATION APPROVAL
This application is not a pern-At until
signed by the Director of Building Inspec-
tion, or his deputy; and fees are paid, and
receipt Is acknowledged in space provided.
DIRECTOR'S HIGNATUR
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