670004.pdfa
BUILDING DEPARTMENT
Applicant Fill
PER MIT APPLICATION
Inside Heavy Lines
NAME (OR "" or BUSIN EBB)
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'7 ki
MAILINO ADDRESS
7 V'/ 7 UV
CITY
TELEPHONE NUMBER
NAME
ADDRESS
CITY
TELEPHONE NUMBER
NAME
04
ADDRESS
CITY
..LEPHONE NUMBER
F4
Z
STATE LICENSE NUMBER
ITY LICENSE NUMBER
Description of Property (Show Below or Attach Four Copies)
A;,J
7
Z
Q
W
0 RESIDENTIAL
GAS
LINE
NEW
1
D"'ADD
1:1
NON-ItESIDENTIAL
SIGN
RETAINING
DDEMOLISH
WALL
E] ALTER
0
EXCAVATE
OR FILL
PENCE
( .......... x .......... Ft.)
REPAIR
F-1
PRE -MOVE
INSP.
SWIM
POOL
NUMBER OF
DWELLING
UNITS
L
9;�67
V
PLOT PLAW —APPROVED
STREET R/W
EXISTING STREET R/W ............ FT -
COMP. PLAN ST. R/W ............ 177-
I-ERMIT
NUMBER 670004
VACANT SITE 4
YES NO
VARIANCE N I R at
DEFICIENCY THIS PROPERTY
3NNECTION VERIFIED BY
�EST PERMIT NURSER
KB
II [I YES [3 NO
SPECIAL INSPECTOR REQUIRED OCCUPANCY GROUP
[:) YES [3 NO
PLAN CHECKE97HY
REMARKS
Plan Check No.
BUILDING
PLUMBING
HEAT & GAS LINE
PENCE
SIGN
RETAINING WATA,
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
I hereby acknowledge that I have read this application; that the In-
formaUOn given in correct; and tha� I am the owner. or the duly author-
Ized agent of tho 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 PER1,11T
rela.Ung to Workmen's Compensation Insurance. AUTHORIZES
ONLY THE
NOTE: Permit Umit One Year (Except DE31OLITIONS which WORK NOTED
shall be completed In ninety days; J%IOVED-IN BUILDINGS shall be com-
pleted In six months.)
3IGNATURE (OWNNA UA DATE 915NED INSPECTION
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Snbject to Plan Check Fee 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.
Valuation Fee Receipt No.
0c,
0 0
2,00
APPLICATION APPROVAL
This application Is not a permit� until
signed by the Buildifig official or his Dep-
uty; and fees,gre paid, and receipt is ac-
lcnowledg�d ii� space provided.
FILE
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