670561.pdfUUILUINU utrAKIMNI AppUcantFW
PERMIT APPLICATION Inside Heavy Lines
NAME OR NA7 OF BUSINESS)
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MAILING ADDRESS
CITY TELEI HONE NUMB1119
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NAME
ADDRESS
CITY I TELEPHOF E NUMBER
NAM JD/b I Col
ADDRE
/V0
TELEPHONE NUMBF
CITY IR
'31
w 7ow or Attacn. ifour c
Jf
20L . 1� I U�?
071
NEW
RESIDENTIAL
I
F�
GAS
LINE
NON-RESIDENTL&L
D
SIGN
D ADD
0
DEMOLISH
RETAINING
WALL
20'�LTER
F1
EXCAVATE
OR FILL
PENCE
( x Ft.)
REPAIR
PRE -MOVE
INSP.
.......... ..........
SWIM
POOL
NUMBER OF STORIES
NUMBER OF
DWELLING
UNITS
NATURE OF WORK TO
iFio uev It i'v\
BE DONE
�A �- le
V__
riuza��
ADDRESS
- I --N,- I 10 YES 0 NO
EXISTING STREET R/W ............ FT- DEFICIENCY THIS PROPERTY
COUP. PLAN ST. R/W ............ FT. ....... .... FT.
0 YES [] NO
Z
L. A0
Plan Check No ............. ... ...
PROPOSED U13E
BUILDING
PLOT PLAN (Indicate Building setbacks, abutting streets)
PLUMBING
ft
HEAT & GAS LINE
PENCE
t
SIGN
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 in correct: and that I am the Owner, or the duly allthor-
lzed agent of the owner. I agree to comply with city and state laws mgu-
ATTENTION
lating constructlon; and In doing the work authorized thereby, no person
will be employed in violation of the Labor Code of the State of Washington
THIS PERMIT
relating to Workman's Compensation Insurance.
AUTHORIZES
NOTE: Permit Limit Ono Year (Except DENIOLITIONS which
ONLY THE
WORK NOTED
shall be Completed In ninety days; I%IOVED-XN BUILDINGS shall be com-
pleted In 01 months.)
SIGNATU WNER OR AGENT) ATE SIGNED
INSPECTION
DEPARTMENT
CITY OF
KDS
NOTE: Applicant Subjcct to Plan Chcck Fce
Pn 6.1107
This PermJt covers work to be done = private property ONLY,
Any construction an the public domain (curbs, sidewalks, drivnTays.
nuwqueest etcJ will require separate permission.
Valuation
0 YES [3 NO
Fee
I ,
NV1 I
It
No.
1 1[41S,11
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.
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