670345.pdfI
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PosrED ON KROLL MAP NO.: PERMIT
BUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION I Inside Heavy Lines
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or
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RESIDENTIAL
GAS
LINE
NEW
NON-RESIDENTIAL
SIGN
0
RETAINING
WALL
DEMOLISH
ALTER
EXCAVATE
PENCE
Ft.)
OR FILL
( ........ . x ..........
REPAIR
PRE -MOVE
INSP.
swim
POOL
14
PAS E.
DWELLING
UNITS
RA
10-
NUMBER
0
3ETBACK
0 /vi o' t4
670345
d-5, I M I I &/ 0
VACANT SITE 94
NO Z
VA'RJANCE NUMBER A.
EN38TING-STREET R/W ............ FT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W ............ FT. ... FT.
REMARKS
IZO
BE
E B CLEARANCE
C CKED BY
WTER
t.- (
FVI
MARKS
E] YES
Plan Check No ................ . ...
PROPOSED USE
Lo I
BUILDING
PLUMBING
I
PLOT
PLAN (Indicate Building setbaCKS, abutti I g s met
HEAT & GAS LINE
FENCE
t
SIGN
FLql)?
#
RETAINING WALL
SWIMMING POOL
V�
33EMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AIMOUNT 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 of the owner. I agree to comply with City and State laws rCgU-
lating construction; and In doing the work authorized thereby. no Person
ATTENTION
will be employed In violation of the Labor Code of the State of Washington
TIUS PER311T
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; DIOVED-IN BUILDINGS shall be com-
pleted In six months.)
INSPECTION
DEPARTMENT
CITY OF
3IGNATURE (OWNER OR AGENT)
DATE SIGNED
EDMONDS
NOTE: Applicant Stibjcct to Plan Check Fce
PR 6.1107
This rerrrdt Covers work to be done on privnte property ONLY.
Any construction on the public domain (curbs, sidewalks. driveways,
marquees, etc.) will r%Nulm separate permission,
Valuation
IER
0�
[] YES 13 NO
I Q 01
Fee Receipt No.
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.
I)ilr8 0 de
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