670547.pdfBUILDING DEPARTMENT ApplicantrIll!
PERMIT APPLICATION Inside Heavy Lines
"ipp I I I NAM (OR NAME OF BUSINESS)
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RESIDENTIAL
flUl, GAS
NEW
LINE
F]
NON-RESIDENTIAL
D SIGN
D DEMOLISH
RETAINING
WALL
EXCAVATE
PENCE
1LTER
OR FULL
( x Ft.)
El
REPAIR
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DWELLING
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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 wlth 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
relsung to Workmen's Compensation Insurance.
NOTE: Permit Limit One Year (Except DEMOLITIONS which
shall be completed in ninety days; 31OVED-IN BUILDINGS shall be com-
pleted in nix months.)
33-1-GNATURE (OWNER OR AGENT) DATE SIGNED
I'A
NOTE: Applicant Snbject to Plan Check Fee
This Permit eovers work to be done on privets property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways.
marquees, etc.) will require separate permission.
MAP NO.: PERMIT
I NUMBER 670547
7
SIDE YARD SETBACK
STREET SETBACK
REAR YARD SETBACK
USE ZONE
LOT AREA
VACANT SITE
ri YES n NO
HEIGHT
BUILDING AKEA
VARIANCE NUAfRER
AW
PLOT PLAN APPROVED
STREET R/W
EXISTING STREET R/W ............ FT. DEFICIENCY THIS PROPERTY
U
COMP. PLAN ST. R/W ............ FT.
REMARKS
0
Z
CHECKED BY
N
METER SIZE SERVICE SIZE CLEARANCE CHECKED BY
Cd
REMARKS
TYPE CONNECTION
VERIFIED BY
PERO. TEST
PERMIT NUMBER
REMARKS
FIRE ZONE TYPE OF CONSTRUCTION STREET IMPROVED
I [] YES [3 NO
SPECIAL INSPECTOR REQUIRED
OCCUPANCY GROUP
[] YES [3 NO
PLAN CHECKED BY
Plan Check No....
BUILDING
PLUMMNG
HEAT & GAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
ATTENTION
TIUS PER!%IIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECT70:q
DEPARTMENT
CITY OF
EDMONDS
PR 6-1107
Valuation I Fee
�W-N
I _�. (b 0 1 V_ 1-3 &7
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.
. :,7 �
— )—,D — � 2
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