670522.pdfBUILDING DEPARTMENT
Applicant M
PERMIT APPLICATION
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TELEPHONE NUMBER
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NAME
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TJOIJUPRONE Nurr ER E
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NAME
ADDRESS
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TELEPHO" NUMBER
WX= WOMSE NUMBER
CITY LICENSE M
LeSM Description of Property (Show Below or Attech Four COP165)
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GAS
RESIDENTIAL LINE
NEW
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NON-R ESMENTIAL r SIGN
ElADD R F TAINING
L1 WALL
DEMOLISH
ElALTER EXCAVATE FENCE
OR FILL ( x Ft.)
........ . ..........
REPAIR PRE -MOVE SWIM
INSP. POOL
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NUMBER or
DWELLING
UNITS
NATURE OF WORK TO 13E DONE
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PROPOSED USE
PLOT PLAN (Indicate Building setbacks, abutting streets)
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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.
lead agent of the owner. I agree to comply with city and state laws regu.
lating construction; mid in doing the work authorized thereby, no person
will be employed in violation of the Labor Code of the State of Washington
rqWAng to Workman's Compensation Insurance.
NOTE: Permit Limit One Year (Except DEMOLITIONS which
ShLU be completed in ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.) A
GE
ED
1�91 NOTE: APPlicant Subject to Plan Check Fee
This permll coven work to be done an private property ONLY.
Any consittUL4jen an the public domain (curbs, sidewalks, driveways,
en"que", 0";) win require separate permission.
KROLL MAP NO.: PERMIT
0 T W I I NUMBER 670522
SETBACK STREET SETBACK REAR TARD SETH,
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LOT AREA VACANT SITE
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KISTING I STREET R/W .......... ST. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W ............ IT. . . . ......
FMARKS
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OQ C4 A
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] YES [3 NO
LEMARKS
?Ian Cheek No
3UILDING
?LUMBING
E[EAT & GAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
ATTEDMON
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PR 6-1107
[] YES [3 No
Fee
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No.
APPLICATION APPRCI�At-)
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.
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