670223.pdff
r BUILDING DEPARTMENT
M17
7ERMT APPUCAM.
Applicant FIII
Inside Ifeavy Lines
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MALLdNG ADDRESS
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413 2 10
CITY— e WE"PRONE NUMBER
rcIMON 173t - 65A I
NAME
-8 A) e-
ADDRESS
CITY TELEPHONE NUM13ER
NAMID
ADDRESS
tut -e,
wELE ER
8 STATE LICENSE NUMBER CITY LICENSE NUMBER
al2cription of Property w w Attach Fo COP
PIMP
Z
Q
QQ
GAS
E] NEW RESIDENTIAL M LINE
I I M NON-RESIDENTIAL I M SIGN
ADD
F1DEMOLISH
D
RETAINING
WALL
EXCAVATE
FENCE
ALTER
F1 OR FILL
El
( X F1.)
REPAIR
PRE -MOVE
INSP.
-1
F
.......... ..........
SWIT11
POOL
DWELLING
UNITS
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I
I hereby acknowledge that I have read this application; that the In-
formation given is correct; and that I ILM the owner, or the duly author.
ized agent of the owner. I agree to comply with city and state laws reru-
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 Workmen's Compensation Insurance.
NOTE: Permit Limit One Year (Except DE31OLITIONS which
shall he completed in ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six nlpnths.) _
�-ZA4 - 6
NOTE: Applicant Subject to Plait Check Fee
This Permit coven work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, drlvewayq,
,marquees, etc.) will require separate permission.
...... ..... 111 I I
NUMBER
3 ADDRESS
p
kCK STREET SETBACK
I k
670223
USE ZONE VACANT SITE
[] YES [3 NO
HEIGHT BUILDING A VARIANCE NUMBER
PLOT P AN APPROVED
STREET R1W
EXISTING STREET R/W ............ FT. DEriciENCY THIS PROPERTY 0
COMP. PLAN ST. R/W ............ FT. ....... .... FT
REMARKS
Z
CHECKED BY
METER SIZE SERVICE SIZE CLEARANCE CHECKED BY
REMARKS
TYPE CONNECTION
VERIFIED BY
PERC. TEST
PERMIT NUMBER
REMARKS
FIRE ZONE TYPE OF CONSTRUCTION STREET IMPROVED
[] YES [:3 NO
SPECIAL INSPECTOR REQUIRED
Ej YES [] NO
OCCUPANCY GROUP
PLAN CHECKED BY
REMARKS
Valuation
Plan Check No...
No.
BUILDING
To
PLUMBING
HEAT & GAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION : —1
EXCAVATION OR FILL
TOTAL A31OUNT DUE
ATMNTION APPLICATION APPROVAL
THIS PERMIT This application is n6t.a permit un�il
AUTHORIZES r his Dep-
ONLY THE signed by the Building Off iclal oi
WORK NOTED uty; and fees are paid, and receipt Is ac-
Imowledged in space provided.
INSPECTION DIRE rT'SIIICINA U
DEPARTMENT
CITY OF
EDMUIN DS
PR 6-1107
FILE
ell
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