670530.pdfBUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION Inside HeaVy Lines I JOB ADDRESS
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NAME
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ADDRESS
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CITY
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STATE LICENSE
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Legal Description of F
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Ft CITY�LICENSE NI
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SIDENTIAL
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F
GAS
LINE
NEW
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NON-RESIDENTIAL
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SIGN
RETAINING
0
WALL
DEMOLISH
EXCAVATE
FENCE
ALTER
OR
D
FULL
( .......... x .......... Ft.)
REPAIR
PRE -MOVE
INSP.
swim
POOL
rumj3ER OF STORIES
NUMBER OF
DWELLING
UNITS
PERMIT
NUMBER
M-P,75 F ;T
0 V
TEO [3 NO
EXISTING STREET n/W ............ FT. DEFICIENCY THIS PROPERTY
COUP. PLAN ST. R/W ............ FT.
0 YES 0 NO
Plan Check No .....................
PROPOSED USE
BUILDING
PLOT PLAN (Indicate Building setbacks, abutting streets)
PLUMBING
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0
HEAT & GAS LINE
5FV_ ATTRQjAE_t) PI-AL)S -
FENCE
SIGN
N
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION 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 of the owner. I agree to comply with city and state Iowa regu-
th mer
'2ed agent of " 0
ATTENTION
lating construction; and in doing the work authorized thereby, no person
letting constfut on
will be employed In violation of the Labor Code of the State of Washington
w, y d In Via"
" be empi�
THIS PERMIT
relating to Workmen's Compensation Insurance.
orkmen' a
AUTHORIZES
NOTE: Permit Limit One Year (Except DE3101ATIONS whIch
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ONLY THE
WORK NOTED
shall be completed in ninety days; MOVED -IN BUILDINGS shall be com-
ted in n
PIL
pleted In six months.)
SIGNATURE (OWNER OR AGENT)
D NED
INSPECTION
A-6-J. 4A&k
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
Pn 0.1107
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, drivewaYs.
marquees, etc.) will require separate permission.
Valuation
3
F*
[] YES [3 NO
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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
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