660277.pdfPOSTED ON KROLL M/
BUILDING DEPARTMENT Applicant Fill
Inside Heavy Lines JOB ADDRESS
PERMIT APPLICATION
' NAME (OR NAME OF BUSINESS) O 6'
i SIDE YARD SETBACK
r MAILING ADDRESS
t • USE ZONE
OI LEPRON NUMBER
HEIGHT
NAME
PLOT PLAN APPROVEI
ADDRESS
.. REMARKS
ER CITY TELEPHONE NUMB
NAME
REMARKS
In U ADDRESS
METER SIZE I SERVI(
CITY I TELEPHONE NUMBER
. .. REMARKS
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STATE LICENSE NUMBER CITY LIOENSE NUMBER
TYPE CONNECTION
Legal Description of Property (Show Below or Attach Four Copies)
PERM TEST
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. FIRE ZONE TYPE
SPECIAL INSPECTOR
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.. � 0 YES NO
PLAN CHECKED BY
BUILDING
WORK TO BE /DONE 00� �//7 I VALUATION
. ■ I / JD J ✓/. �,_ / G g BUILDING PERMIT
1 FEE
u NEW O LiSIGN
Q ADD DEM01
OLISH �NCE
n ALTER I RESIDENTIAL I NUMBER OF
DWELLING
EjREPAIR NON-RESIDENTIAL UNITS
• PROPOBffiD UBffi
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-
ized agent of the owner. I agree to comply with city and state laws regu-
lating construction; and In doing the work authorized thereby, no pareon
will be employed in violation of the Labor Code of the State of Washington
relating to Workmen's Compensation Insurance.
• (Except Demolitions which ehNl
NO a Permit Limit One Year ba completed In ninety days.)
N ORE (OWNER OR AOEN DATffi SIGNED
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NOTE: Applicant Subject to Plan Check Fee
This Permit coven work to be done on prh•ate property ONLY.
Any construction on the public domaln (curbs, sidewalks, driveways,
marquees, etc.) will require separate perml'slon.
0
41 HEAT & GAS
PERMIT FEE
SIGN PERMIT
6 FEE
s
ATTENTION APPLICATION APPROVAL
This PERMIT This application Is not a permit until ,
AUTHORIZES signed by the Director of Building Inspec
ONLY THE
WORK NOTED tion, or his deputy; and fees are paid, and
receipt is acknowledged in space provided.
INSPECTION DIRECTOR'S SIGNATURE
DEPARTMENT /
CITY OF w
EDMONDS DATE
PR 0-1107
FILE
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