670216.pdfIM..
BUILDING DEPARTMENT Applicant FIR
inside Heavy Lines
PERMIT APPLICATION
NAME (OR NAME OF BUSINESS)
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MAILING ADDRESS
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CITY U10—UPRONE 14UMBLR
WA). 61t t -.2.670 0
NUMBER
)13 "VICEus -1 q6 C) k_') yj'4�
USE ZONE LOT AREA VACAME 151:1'N
1 1 [3 YES E3 NO
HEIGHT — I BUILDING "LEA I Vj I
ADDRESS
sTREET R/W
7TTI—T TELEPHONE NUMBER
EXISTING STREET R/W ............ FT. D101FICIEZICY THIS PROPERTY
COUP. PLAN ST. R/W ............
FT. .......... 1".
REMARKS
NAMM
OW "%71
CHECKED BY
z
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—NUMBER
METER SIZE SERVICE SIZE
CLEARANCE CHECK= By
orry TELEPHONE
S Er,�9 7T A- 6JAM F�A' $/- 2-k.2 -3
REMARKS
STATE LICENSE NUMB CITY LLUJUNBE riuhl"Nn
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TYPE CONNECTION
VERIFIED 13Y
Legal Description of Property (Show Below or Attach Four Copies)
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PERC. TEST
PERMIT NUMBER
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V
REMARKS
M
13 YES E3 NO
SPECIAL INSPECTOR REQUIRED OCCUPANCY GROUP
13 YES 13 NO I
NEW RESIDENTIAL
NON-RESIDENTIAL
DEMOLISH
ALTER EXCAVATE
OR FILL
REPAIR PRE -MOVE
INSP.
El
0
GAS
LINE
SIGN
RETAINING
WALL
FENCE
( .......... x .......... Ft.)
swim
POOL
rUMBER OF STORIES
NUMBER OF
DWELLING
UNITS
TATURE OF WORK TD BE DONE
Igo/
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V
Plan Check No ................ . ...
PROPOSED USE
BUILDING
PLOT PLAN (Indicate Building setbacks, abutting streets)
PLUMBING
I
HEAT & GAS LINE
FENCE
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-
formation given Is a orrect; and that I am the owner, or the duly author-
Ized agent of the owner. I agree to comply with city and state lawn regu-
ATTENTION
lating construction; and In doing the work authorized thereby, no person
will be employed In viDlatlon of the Labor Code of the State of Washington
THIS PEMnT
relating to Workmen's 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 CDM-
plated In six months.)
SIGNATURE (OWNER OR AGENT)
DATE SIGNED
INSPECTION
DEPARTMENT
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CITY OF
V
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
PR 6-1107
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
nuarquees, etc.) will require separate permission.
Valuation
(9 *4
Fee
-7, 5� 0 1 .3 "? 6 C,
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.
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