660076.pdfa
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j&PIN6 DEPARTMENT Applicant Fill
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IT_,`;- APPLICATION I
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SIDE YA D
SETBACK
STREET SETE�ACK
HEAR YARD ETBACK
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NM
REA
YACANT SITE
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13 YES [3 NO 0
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HT
BUILDING AREA
NCE NUMBER
V V NUMB
ARIA
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99 TU
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iCITY TELEPHONE NUMBER
FR
rol
ION VERIFIEDy
S�� INSPECTOR REQUIR
0 YES
_� /I OR 0 n) Ls 1 -0 U W L-4 W QA rl
1
BUILDING
VALUATION
WORIC TO BE DONE
2
BUILDING PERMIT
FEE
PLUMBING
3
PERMIT FEE
0
HEAT & GAS LINE
4
PERMIT FEE
5
—
6
MADD
NEW
EE28H
1
0 SIGN
El MNCE
NUMBM OF STORIES
SIGN PERMIT
FEE
DEMOLITION
PERMIT FEE
ALTER
REPAIRI
RESIDENTIAL
NON-RESIDENTIAL
NUI:ER OF
DW LING
UNITS
71
PLAN CHECK
FEE
PROPOSED USE
8
AMO
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.
ATTENT ION
ized agent of the owner. I agree to comply with city and state laws regU-
THIS PEWIIT
I construction; and In doing the work authorized thereby. no person
AUTHORIZES
ill be employed in violation Of the Labor Code of the State of Washington
w v4 4
ONLY THE
Llating
rel atl ng to Workmen's Compensation Insurance.
WORK NOTED
N1 Demolitions which shall
OTE: Permit Limit One Year be completed in ninety . days.)
I i TURE (OWNNR �R,�GENT) DATE SIGN ED
87
INSPECTION
DEPARTMENT
0 e-b �
Crry OF
EDMONDS
NOTE: Applicant Sitbject to Plan Check Fee
PR 6.1107
This Permit covers Work to be done on private property ONLY.
Any construction on the public domain (curbs. sidewalks, driveways,
marquees, etc.) Will M4ulre Separate PCM11"loo'
0 YES 0 NO
FSK
0101
71 1 & a, S-0 I
APPLICATION APPROVAL
This application is not a pem-dt until
signed by the Director of Building Inspec-
tion, or his deputy; and fees are paid, and
receipt Is acknowledged in space provided.
DIRUCTOR'S SIGNATURE
DATE
LI/
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FILE
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