670010.pdfPnEvrpD ON KROLL MAP NO.:
I PERMIT
1,Q'ILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION Inside Heavy Lines
NAME (OR NA2= OF BUSINESS)
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CITY TELEPHONE NUMBIUR
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PRESS
TELEPHONE UMBER
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CITY %M"MONE NUMB
STATE LICENSE NUMBER CITY LICENSE NUI
Legal Description of Proper�y (Show Below or Attach Four Coplf
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GAS
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NON-RESIDI TIAL
SIGN
RETAINING
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WALL
ALTER
DEMOLISH
EXCAVATE
OR FILL
FENCE
( x Ft.)
.......... ..........
REPAIR
PRE -MOVE
INSP.
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POOL
STREET BETE
LOT AREA
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,RIANCE NUMBffR__j ow
EXISTING STREET V1W ............ FT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W ............ FT. ........... ITT.
REMARK9'
I UNITS
NATURE OF WORK TO BE DONE
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I hereby acknowledge that I have read this application; that the in-
formation given to 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 WorkmerVe Compensation Insurance.
NOTE: Permit Limit One Year (Except DEMOLITIONS which
shall be completed in ninety days; MOVED -IN BUILDINGS shall be com-
pleted in six months.)
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NOTE: APPlicalni(Subject to Plan Check Fee
This Permit coven work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marquees, etc.) win require separate permission.
OF
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Plan Check No ......
BUILDING
PLUMRING
HEAT & GAS LINE
PENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
ATI!ENTION
TIUS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PR 6-1107
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CHECKED BY rz
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d No
Fee I Receipt No.
1. �-o
APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or hi� Dep-
uty; and fees are paid, and receipt is ac-
knowledged in space provided.
!FI—RECTOWS SIGNATURX A
DATE &
R
FILE
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