670032.pdf2.- _i_�
M
BUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION Inside Heavy Lines
NAME (OR NAME OF BUSINESS)
IvI4,41.5
MAILING ADDRESS
TELEPHONE WffffffiaR
7 -71
NAME
j�)U�) A_J 0 lt�
ADDRESS
0 to
,9,0 4tV1
A.
NEW
Li RESIDENTIAL
GAS
LINE
1
11
NON-RESIDENTIAL
F�
ADD
SIGN
RETAINING
D
0
WALL
DEMOLISH
EXCAVATE
PENCE
ALTER
F
OR FILL
( x I%.)
El REPAIR
PRE -MOVE
El
.......... ..........
swim
INSP.
POOL
rUMBER OF STORIES
I NUMBER (OF
DWELLING
UNITS
j.),-0 -
ON
1��
ST EET RIW
EXISTING STREET R/W
COMP. PLAN ST. RAV .......
[] YES [] NO
Plan Check No .....................
PROPOSED USE
BUILDING
PLUMBING
PLOT PLAN (Indicate Building setbacks, abutting streets)
BEAT & GAS LINE
PENCE
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
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-
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
NOTE: Permit Limit One Year (Except DEMOLITIONS which
ONLY THE
WORK NOTED
sheal be completed in ninety days; MOVED -IN BUILDINGS shall be Com-
Pleted In six months.)
3IGNATURE (OWNER OR AGENT)
DATE SIGNED
INSPECTION
7
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
Pit 0-1107
This Permit covers work to be done an private property ONLY.
Any construction on the public domain (curbso sidewalks, driveways,
nuLrquees. etc.) will require separate permission.
I I
tion No.
Value Fee
U
I Z) , 0 b I
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.
DATE'
Fitz
I
t
e
m