660012.pdft
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NAME (OR N a)
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W a 7' fv*
�MAILJNG ADDRESS
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NAME
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CITY
TELEPHONE NUMBER
STATE LICENSE NUMBER
CITY LICENSE NUMBER
Legal Description of Prop rty (Show Below or Attach Four Copies)
6)
4'riLt
TYPE OF
'Iyerards o4 S'whomish (.6mlv,"A []YES 0 NO
PLAN CHECKED BY
BUILDING
VALUATION
WORK TO BE DONE
)?eyyLoAP,L,-,q (S Q-4-ne I h +tb)
BUILDING PERMIT
0
2
3
FEE
PLUMBING
PERMIT FEE
HEAT & GAS LINE
0
4
PERMIT FEE
SIGN PERMIT
FEE
E]
NEW
ADD
D
SIGN
PENCE
NUMBER OF STORIES
5
DEMOLITION
PERMIT FEE
ALTER
REPAIR
r7i
Pj RESIDENTIAL
NON-RESIDENTIAL
NUM' .. R OF
B
DWELLING
UNITS
6
7
PLAN CHECK
FEE
PROPOSED USE
I
taw�i �v room
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
lzed agent of the owner. I agree to comply with city and state laws regu-
THIS PER1111IT
lating construction; and in doing the vrork authorized thereby. no person
will be employed In violation of the Labor Code of the State of Washington
AUTHORIZES
ONLY TIIE
relaUng 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) A E SIGNED
INSPECTION
A)
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Subject to Plats Check Fee
PR 6-1107
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveway",
marquees, etc.) will require separate permInslon.
PERMIT
NUMBER
[] YES
[3 NO 0
UMBER I
ILI
STREET PWROVI
0 YES 0 NO
1 � - � h:L 11
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 aelmowledged in space provided.
FILE
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