660565.pdfBUILDING DEPARTMENT Applicant Fin
PERMIT APPLICA1 Inside Heavy Lines
__7_
1117W
ADDRESS
CITY
-le-0
or
97A
5
!2
NEW
119—D
ALTER
REPAIR
D—RESIDENTIAL
1 11
RDEMOLISH
F1
R
NON-RESMENTIAL
EXCAVATE
OR FILL
PRE -MOVE
INSP.
GAS
LINE
SIGN
RETAINING
WALL
PENCE
( ......... �x .......... Ft.)
swim
POOL
ES_
NUMBER OF
DWELLING
UNITS
ON KROLL MAP NO-:
IRESS I V__ �
PERMIT
NUMBER 660560
,/1 - fa CA-
USE ZONE OT A.REA VACANT SITE
0 YES 0 NO
MIANGN 14U�zn 100
A
PERTY
EXISTING STREET R/W ............ FT- DEFICIENCY THIS PRO
COMP. PLAN ST. R/W ........... ST. ....... .... FT.
REMARKS
CKED BY Z
Fa
METER SIZE SERVICE SIZE CLEARANCE CHECKED BY
REMARKS
[] YES
TYPE
AM.
Flan Check No .....................
PROPOSED USE BUILDING
PLOT PLAN (Indicate Building setbaCICB, abutting streets) PLUMBING
HEAT & GAS IANE
PENCE
t SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL A31OUNT DUE
I hereby acknowledge that I have read this application; that the In-
formatlon given is correct; and that I am the owner, or the duly author-
lzed agent of the owner. I agree to comply with city and state laws regu- ATTENTION
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 THIS PERMIT
relatIng to Workmen's Compensation Insurance. AUTHORIZES
ONLY THE
NOTE: Permit Limit One Year (Except DE31OLITIONS which IVORK NOTED
shall be completed in ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.) ED INSPECTION
SIGNATURE (OV T) DATE SIGN
,�YER OR
'7 1 DEPARTMENT
CITY OF
L EDIVIONDS
ggNOTE: APP Kicant Subject to Plan Check Fce PR 0-1107
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.
[3YES 0 NO
Fee
No.
5, 60 v 1( 3 -/� o'
APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or his Dep-
uty; and fees are paid, and receipt Is ac-
knowledged in space provided.
DIRVO'e'S IONAT
7Z
FILE
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