670087.pdf-1
BUILDING DEPARTMENT
PERMIT APPLICATION
or
Applicant Fill
Inside Heavy Lines
DNEW
RESIDENTIAL
GAS
LINE
NON-RESIDENTIAL
SIGN
ADD
0
DEMOLISH
=AINING
WALL
EJALTER
0
EXCAVATE
OR FILL
FENCE
( x Ft.)
.......... ..........
REPAIR
—
PRE -MOVE
INSP.
swim
POOL
IUMBER OF STORIES
NUMBEA UIC
DWELLING
UNITS
ON KROLL MAP NO.:
PERMIT
I NUMBER
670087
DRESS
'..:2 /
— / 4� �' -:�Vr
ARD SETBACK
STREET SETBACK
REAR YARD SETBACK
ju,r AREA
vAcAWK SITE��
ONE
[3 YES NO
�ow
I nTff_LT31W0 AnEX
I VAI R
STREET R/W ............ FT. DEFICIENCY THIS PROPERTY 0
PLAN ST. R/W ............ Fr. ........... 1".
CHECKED BY A
[] YES Z�-�O
Z
Agin
Plan Check No ..................
PROPOSED E
BUILDING
PLOT PLAN (indicate 13ullaing setbacks, abutting streets)
PLUMBING
19
0
ft
HEAT & GAS LINE
PENCE
t
SIGN
N
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 In correct; and that I am the owner, or the duly author.
ized agent of the owner. I agreo 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
TIUS PERMIT
relating to Workmens Compensation Insurance.
AUTHORIZES
NOTE: Permit Limit One Year (Except DEMOLITIONS which
ONLY THE
WORK NOTED
shall be completed in ninety days; MOVED -IN BUILDINGS shall be com-
pleted in six months.)
SIGNATURE (OWNER OR AGENT) DATE SIGNED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
PR 0.1101
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (embs, sidewalks, driveways,
marquees, etc.) will require separate permission.
[3 YES &1�0
Valuation I Fee I Receipt No.
RRTWE
)e
APPLICATION APPROVAL
TiUs application is not a permit until
signed by the Building Official or We Dep-
uty; and fees are paid, and receipt Is ac-
knowledged In space provided.
DI CTOR'S SIGNAT
Z)
FILE
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