670240.pdfBUILDING DEPARTMENT
PERMIT APPLICATION
NAME (OR NAME OF BUSINESS)
CH,4XJ_9FS r-, C
MAILING ADDRESS
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CITY
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I NAME
N ADDRESS
CITY
Applicant Fill
Inside Heavy Lines
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NAME
A,
ADDRESS
2- �7 — UJ
TELEPHONE NUMBER
STATE LICENSE NUMBER
CITY LICENSE NUMBER
Z:�3_01 _. / 4 ( 0
1 1
Legal Description of Property (Show Below
or Attach Four Copies)
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GAS
LINE
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[0 NON-RESIDENTIAL F] SIGN
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DADD
F] DEMOLISH
RETAINING
WALL
ElALTER EXCAVATE
0 OR FILL
FENCE
( .......... x .......... Ft.)
REPAIR PRE -MOVE
1:3 INSP.
swim
POOL
__ES
NUMBER OF STORIES
NUMH
I —NUMBER OF
DWELLING
UNITS
Mov 6
3;
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ON KROLL MAP NO.: PERMIT
NUMBER 6'70240
kRD SETBACK STREET SETBACK REAR YARD SETBACK
- NE ------- LOT AREA CANT SITE
I [] YES [3 NO
BUILDINO JU�& VAI"NUN LW�UER
1 04
EXISTING STREET R/W ............ FT.
COMP. PLAN ST. R/W _ ......... FT.
NECTION
TYPE OF:
DEFICIENCY THIS PROPERTY
[3 YES kT<
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[] YES —7�
PLAN CHECKED
REMONS
0,
Plan Check No .....................
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P I an C e c N
I L D I N G
BUILDING
U
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PLU NG
P L U
N E
HEAT & GAS LINE
IE A T G A 8
N
FENCE
F E C
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I G N
SIGN
N
IRETAINING
j
WALL
I
E I N G WA:
R T A I N
MI G POOL
WIMMING POOL
S M
EM
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
L %I .
TOTA A . OU ,T DUE
TOTAL A31OUNT DUE
I hereby acknowledge that I have read thin application; that the In-
formation given is 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 ron3truction; and In doing the work authorized thereby. no person
will be employed In violation of the Labor Code of the State of Waahington
relating to Workmen's Compensation Insurance.
NOTE: Permit Limit One Year (Except BE31OLITIONS which
shall be completed In ninety days; MOVED -IN' BUILDINGS shall be com-
pleted In six months.)
UONATURE (OWNER OR AGENT) DATE SIGNED
P 0
NOTE: Applicant Subject to Plait Check Fee
—im—apermit covers work to be done on private property
Any construction on the public domain (curbs, sidewalks, driveways,
marquees, etc.) will require separate permission.
ATTENTION
THIS PERIVIIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PR 0-1107
Valuation
490
Fee
No.
L;? - 19 0 1 37��j
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.
FILE