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BUILDING DEPARTMENT Applicant Fill
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FIPERMIT APPLICATION
'12 NAME (OR NAME UFRUSINESS)
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AILING ADDRESS
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CITY 2 NUMBER
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PERMIT
NUMBER 6,5043
DDRESS r
YARD SETBACK STREET SETBACK SETS
7ZONE LOT AREA VACANT SITE
0 ErYEB 0 NO
[3 YES
WORK TO BE DONE
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PLUMB NG
PERMIT FEE
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0
HEAT & GAB LINE
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PERMIT FEE
5
SIGN PERMIT
FEE
A
0—NEW
ADD
EJ SIGN
DE FENCE
NU14BE R OF STORIES
DEMOLITION
:1 ALTER
DREPAIR
RESIDENTIAL
1 Z
NON-RESI
NUMBER OF
DWELLING
UNITS
6
PERMIT FEE
7
PLAN CHECK
FES
NT 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 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.)
INSPECTION
NED
Slork[ATURE (OWNER 0111 ArGT) DATE SIG 3— DEPARTMENT
A, CITY OF
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EDMONDS
NOTE: Applicant Subject to Plan Check Fee Pit 6.1101
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XARANCE CHECKED BY
99
BY
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fSTRE T IMPROVED
l[3 YES [3 No
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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 aclmowledged in space provided.
DATE
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways, FILE
marquees, etc.) will require separate permission.
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