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NAME (OR NAME OF BUSINESS)
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SIDE YARD SETBACKJ
USWNE
STREET SETBACK
LOT AREA
REAR YARD Smnxcic
VACANT SITE
MAILING ADDRESS
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CITY
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RESIDENTIAL
GAS
LINE
NEW
I
ErNON-RESIDENTI&L
El
SIGN
DEMOLISH
RETAINING
WALL
ALTER
D
EXCAVATE
OR FILL
PENCE
( x Ft.)
.......... ..........
E] REPAIR
F�
PRE -MOVE
INSP.
ET
SWIM
POOL
DWELLING
UNITS
4
,c�
L
AP,
t
N
R.FC. AM _fP1
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 of the owner. I agree to comply with city and state laws regu-
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 DEMOLITIONS which
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
UGNATURE AGENT) DATE SIGNED
NOTE: Applicant Subject to Plan Check Fee
This Permit covers work to be done on private Property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways.
nuu�qucss, etc.) will require separate Permission.
k%
EXISTING STREET R/W ... ........ FT.
COMP. PLAN ST. R/W ............ FT,
0 YES [3 NO
DEFICIENCY THIS PROPERTY
FIRE ZONE TYPE OF CONSTRUCTION STRE T IMPROVED
[3 YES NO
SPECIAL INSPECTOR REQUIRED OCCUPANCY GROUP
[3 YES [3 NO
PLAN CHECKED BY
REMARKS
Plan Check No.
BUILDING
PLUMBING
HEAT & GAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
ATMNTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDBIONDS
Pit 0-1107
Valuation
�&" <9C)
Fee
APPLICATION APPROVAL
No.
This application is not a permit until
signed by the Building Official or his Dep-
uty; and fees are paid, and recelpi I
knowledged in space provided.
DATE
FILE
10000
m