650429.pdfr
BUILDING DEPARTMENT Applicant FIU
0' 4 PERMIT APPLICATION Inside Heavy Lines
NAME (OR NAME Or BUISINEUS)
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TN"rliUNE NUMBXR
CITY
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CITY TELEPHONE NUMBER
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D-1 PLAT OF C D)q 0 IV 0
)N KROLL MAP N= BUILDING
PERMIT
NUMBER
IESS
ZONE
[] YES [] NO
I
1
BUILDING
VALUATION
WORFICO BE DONE
4
e
BUILDING PERMIT
2
2
FEE
__eMe;y.1
3
3
PLUMBING
PERMIT FEE
BEAT & GAS LINE
4
PERMIT FEE
NEW
SIGN
NUMBER OF ISTORIES
SIGN PERMIT
04
ADD
DE MOLI fill
0 PENCE
5
FEE
6
6
DEMOLITION
PERMIT FEE
ALTER
Q RESIDENTIAL
. OF
rR
NUMBER OF
a
DWELLING
PLAN CHECK
REPAIR
NON-RESIDENTLAL
UNITS
7
FEE
PROPOSED USE
8 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 duly author� ATTENTION
Ized agent of the owner. I agree to Comply With city and state laws regu- THIS PEI13UT
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 Umit One Year be completed In ninety days.)
_= 7T (OWNER OR AGE DA INSPECTION
DEPARTMENT
CITY OF
EDMONDS
NOIE: Applicant Subject to Plan Check Fee PH 6-1107
This permit coven work to be done on private property ONLY.
Any construction an the public domain (curbs, sidewalks. driveways,
marquees, etc.) will require separate permismlon.
650429
13 YES 13 NO
0 YES 0 NO
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4
I
Z
1 1 .57, 1 1 1
APPLICATION APPROVAL
This application is not a pemiit until
signed by the Director of Building Inspec-
tion, or his deputy; and fees are paid, and
receipt Is aclmowledged In space provided.
�/// A,/ j
FILE
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