660425.pdfDEPARTMENT
APPLICATION
W A4 r-01
V
I
t
or
da r Poe I"
NEW I [:] I " SIGN
ADD DEMOLISH 111 FENCE
ALTER I N RESIDENTIAL
REPAIR M NON-RESIDENTIAI
R1
Applicant Fill
Inside Heavy Lines
7 J� 0 10'
NUMBER OF
DWELLING
UNITS
I hereby "knowledge that I 'have read this application; that the in-
formation given In 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 person
will be employed In violation of the Labor Code of the State of Washington
relating to WorkmeWs Compensation Insurance.
,,,,,pl Demolitions which shall
NOTE: Permit Limit One Your be completed In ninety days.)
4IGNATURE (OWNER OR
,AGENT) DATE SIGNED
NOTE: Applicant Sub)U to Plan Check Fee
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marquees. etc.) will require separate permission.
MDREBS
0
[] YES [3 NO
BUILDING
I
VALUATION
BUILDING PERMIT
2
FEE
PLUMBING
3
PERMIT FEE
HEAT & GAS LINE
4
PERMIT FEE
SIGN PERMIT
5
FEE
DEMOLITION
6
PERMIT FEE
7 1 PFLEAN CHECK
8 1 AMOUNT DUE
ATTIUNTION
THIS PERMT
AUTHORIZES
ONLY THE
JVORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PR 6-1107
:3. 0 0
95
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 helmowledged in space provided.
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