650316.pdf..........
I KROLL MAP NO.:
i%RTMENT Applicant Fill
ICATIONInside Heavy Lines JOB ADDRESS
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TELIEkWurflu NUMBER
4
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7
TELEPHONE NX
7 9-9
STATE LICENSE NUMBER
CITY LICENSE NUI
Legal Description of Proper
or Attach Four Cople
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4Z of Way ;% At-.5 Add.) Sii�PaI`� i,n rl, c r ..�.j i v
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PERMIT
NUMBER
Kj STREET SETBA(
if � _-2 j � Ag
16
13 YES 13 NO
VARIANCE NUMBER
1 -3 1 1 E3 YES 13 NO
SPECLALL INSPECTOR REQUIRED JOCCUFANCT GROUP
0 YES �r �0 I
IA41E)WD
Lj SIGN
I
DEMOLISH
I El FENCE
ALTER
RESIDENTIAL
NUMH
BER OF
I
E]
REPAIR
NON-RESIDENTIAL
DWELLING
UNITS
I 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-
Ized agent of the owner. I agree to comply with city and state laws regu-
lathig 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.
(Except Demolitions which shall
NOTE: Permit Limit One Your be completed in ninety days.)
NOTE: Applicant Subject to Plan Check Fee
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (eurbs, sidewalks, drivewayn.
marquees, etc.) will rrqtdn separate permission.
BUILDING
VALUATION
BUILDING PERMIT
2
FEE
PLUMBING
3
PERMIT PER
HEAT & GAS LINE
4
PERMIT FEE
SIGN PERMIT
5
FEE
DEMOLITION
6
PERMIT FEE
PLAN CHECK
7
FEE
8 1 AMOUNT DUE
AT=NTION I APPLICATION APPROVAL
THIS PEW41T 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
receipt is acknowledged in space provided.
INSPECTION DIRECTOR'S SIONATUAM
DEPARTMENT
CITY OF
EDMONDS
PH 6-1107 � AX/461
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