660495.pdf�OSTED ON KROLL MAP NC
BBUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION Inside Heavy Lines ADDRESS
NAME (OR NAME OF BUSINESS)
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CITY TELEPHONE NUMBER
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STATE LICENSE NUMl:WIt
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660495
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WORK TO BE DONE
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VALUATION
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BUILDING PERMIT
FEE
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PERMIT FEE
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PERMIT I=
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SIGN
NUMBER OF
SIGN PERMIT
ADD
DEMOLISH
PENCE
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FEE
DEMOLITION
PERMIT FEE
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ALTER,
REPAIR
RESIDENT IAL
1:1 NON-RESIDENTIAL
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NUMBER OF
DWELLING
UNITS
PLAN CHECK 20
FEE
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1 AMOUNT DUE
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I hereby acknowledge that I have read this application; that the in-
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formation given Is correct; and that I am the owner, or the duly author-
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Ized agent of the owner. I agree to comply with city and state laws regu-
THIS PERMIT
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lating construction; and in doing the work authorizzad thereby. no person
AUTHORIZES
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will be employed In violation of the Labor Code of the State of Washington
ONLY THE
relating to Workmen's Compensation Insurance.
11VORK NOTED
(Except Demolitions which shall
NOTE: Permit Limit One Your be completed in ninety days.)
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IIGNATUW (OWNER OR AGENT) DATE SIGNED
INSPECTION
DEPARTMENT
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CITY OF
ED31ONDS
NOTE: Ayplicant Subject to Plan Check Fee
PR 6-1107
This Permit covegs work to be done on private Property ONLY.
Any construction on the public domain (curb@, sidewalks, driveways,
m"queeze etc,) will require separate permission,
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[:] No
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 to acknowledged in space provided.
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