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F BUSINESS) JOB ADDRESS
V) C-4 SLDW YARD j3ACK I REAR YARD
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low it MAP NUMBER T SITE
V 411 1 e VACANT SITE
TELEPHONE N I rd 15 MM u8E ZONE
LoA, 10j, C? rn Ej YES NO
REA I VARIANCE NUMBER
HEIGHT ALL BUILDING SETBACKS
NOTE: TO EAVF, LINES
E PHONE NUMBER
a� GRADE
-Encroachment Permit PERMIT NUMBER STREET
Required 0 NO
0
ICE SIZE ICRECKED By
TE PHONE NUMBER METER SIZE SERV
E LICENSE NUMBER ITY LICENSE NUMBER REMARKS
TRACT
LOT
u TYPE CONNECTION BY
PERC. TEST
PERMIT NUMBER
LIOUEET MPHO
IRE ZONE TYPE OF CONSTRUCTION STREET ImPnOVED
0 a N:D
YES NO
'OCCUPANCY GROUP
z SPECIAL INSPECTOR REQUIRED
YES NO
PLAN CHECKED By
Q
92 WORK TO BE DONE No. OF BLOGS. PERIBLOO. TOTAL FEE z
BUILDING
v ALUATION
BUILDING PERMIT
L 2
C CL FEE
Nuzdb�n U.
EW DEMOLISH PLUMBING
3 PERMIT FEE
ADD HEAT & GAS LINE
Ivi NUMBER*Op 4 PERMIT FEE
ALTER RESIDENT DWELLING
DEMOLITION
REPAIR NON-RESI AL UNITS 5 PERMIT FEE
-FR-01
6 AMOUNT DUE 1,�r
CA (I (-I
r
Ive read this application; that the in -
I hereby acknowlelge that I author. ATTENTION APPLICATION APPROVAL
formation given is correct; and that I am the owner, or the duly
ized agent of the owner. I agree to Comply with city and state laws regu- THIS PERMIT This application Is not a permit until
lating construction; and in doing the work authorized thereby, no person AUTH0IUZES signed by the Director of Building Inspee-
will be employed in violation Of the Labor Code of the State of Washington ONLY THE
WORK NOTED tion, or his deputy; and fees are paid, and
relating to Workmen's Compensation Insurance. receipt Is aelmowledged in space provided.
NOTE: PERMIT LIMIT ONE YEAR INSPECTION DIRECTOR'S SIGNATURE
10NATUP-E (OWNDR OR AGENT) DATE SIGNED DEPARTMENT
-71 ic eX )26e"qet-te� CITY OF
DATN 4,1
TIOVED, ED31ONDS
PL5'-f PLAN CHECK & XPP
PR 6-1107
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