650359.pdfBUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION Inside Heavy Lines
NAXE (0 AME OF BUSINESS)
MAILING ADDRESS
CITY
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TELEPHONE NUMBER
NAME
ADDRESS
CITY
TELEPHONE NUMBER
NAMM
ADDRESS
CITY
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TELEPHONE NUMBER
STATE LICENSE NUMBER
CITY LICENSE NUMBER
Legal Description of Property (Show Below or Attach Four Copies)
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IOSTED ON KROLL MAP NO.: BUILDING
PERMIT
I
650359
NUMBER
JOB ADDRESS
'2
e2 i:_�
e:7
SIDE YARD BETBAC14
REAR YARD BET73ACK
USE ZORF-
LOT AJtEA
VACANT SITE
0 YES [3 NO
HEIGHT I
BUILDING AREA
VARIANCE NUMBER
At
j
PLOT PLAN APPROVED
REMARKS
REMAKKS
METER SIZE SERVICE
SIZE CLEARANCE
CHECKED BY
REMARKS
TYPE CONNECTION
VERIFIED BY
Cal
PERC. TEST
PERMIT NUMBER
FIRE ZONE TYPE OF CONSTRUCT70N
STREET IMPROVED
YES NO
[3 YES [j NO
13LAN CHECKED BY
BUILDING
WORK TZO BE DONE 1 VALUATION
5,3 BUILDING PERMIT
2 FEE
150 31,, PLUMBING
Y, 1 3 PERMIT FEE
'72 /0 Y-1 61 — HEAT & GAS LINE
4 PERMIT FEE
SIGN NUMBER OF STORIES SIGN PERMIT
5 FEE
El 1AqD@WD I DEM[OLISH FUI
FENCE — DEMOLITION
ALTER SIDENTIAL �ER OF 6 PERMIT FEE
rWME LING — PL CB Ec�..�
REPAIR NON-REsrDENTIAL UNITS 7
PROPOSED USE
8 AMOUNT DUE
I hereby acknowledge that I have read this application; that the In.
formation given Is correct; and that I am the owner, or the duty author- ATTENTION
ized 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 Workmen's Compensation Insurance. WORK NOTED
(Except Demolitions which shall
NOTE: Permit Limit One Year be completed in ninety days..)
SIGNATURE (OWNER OR AGENT DATE qIGNED INSPECTION
IleDEPARTMENT
Z CITY OF
dOTE: APPfirant Subject to Plan Check Fce EDMONDS
This rermit covm work to be done on private property ONLi7.— PR 6-1107
Any construction on the public domain (curbs, sidewalks, driveways,
marqueest etc,) will require sepwrnte permission.
Fam
APPLICATION APPROVAL
This application is not a permit until
signed by the Director of Building Inspec-
tion, or his deputy; and fees are paid, and
receipt Is acknowleog!ad in space provided.
AI
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