670249.pdfZ
BUILDING DEPARTMENT
PERMIT APPLICATION
NAME (OR NAME OF BUS1 as)
C b a I- � < _S A P
MAIL,ING ADDRESS
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WDRESS
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CATE LICENSAUUM01
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agal Description of Property (She
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Applicant FIR
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630249
STED ON KROLL MAP NO.: PERMI -in?49
lao NUMB= 6,
I ADDRESS
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)E YARD SETBACK STREET SETBACK REAR YARD uETBA
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lE Z NE LOW AREA VACANT SITE
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EXISTING STREVI! R/W.d/:n!e,FT. DEFICIENCY
COMP. PLAN ST. ..4
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X1 RESIDENTIAL
NEW
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GAS
LINE R EMAPJW
ElNON-RESIDENTIAL
11
ADD �
SIGN
RDEMOLISH
RETAINING
WALL
EXCAVATE
PENCE
ALTER
R OR FILL
( X Ft.)
REPAIR PRE -MOVE
11 INSP.
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.......... ..........
swim
POOL
DWE ING
0 4NUM��ER OF—
.,UNITS
e v\j c 0 r-1 S-n- U C_ T) � 1)
P
K e n
Plan Check No .....................
PROPOSED USE
BUILDING
PLOT PLAN (Indicate-BUIlding setbacks, abutting streets)
PLUMBING
HEAT & GAS LINE
PENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVAT10N OR FILL
TOTAL AMOUNT DUE
I hereby acknowledge that I have read this application; that the in-
formation given Is correct; and that I am the owner. or the duly author-
ized agent ef the owner. I agree to comply with city and state laws regu-
ATMNTION
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 Workman's Compensation Insurance.
AUT1IOlUZES
NOTE: Permit Limit One Year (Except DE31OLITIONS which
ONLY THE
WORH NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
SIGNATURE (OWNER 0 GEN DATE SIGNED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Subject to Plait Check Fee
PR 6.1107
This Pernilt covers work to be done on private property ONLY
Any construction on the public domain (curbs, sidewalks, driveways,
�qjjcca, etc.) will require separate permission.
PROPERTY
I
0 YES
al
No.
APPLICATION APPROVAL
This application Is riot 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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FILE
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