680093.pdfPOSTED ON XROLL MAP N
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BUILDING- DEPARTMENT Applicant FM
. APPLICATION
Inside Heavy Lines
JOBADDRESS
NAME (OR NAMEJOF 15USINEBY
OR
FPERMIT
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SIDE YARD SETBACK
57
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13
113
CITY
TELEPHONIC NUMBER
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jEDN0tVP3
Pj?6 IC76
HEIGHT
S E-(, F-
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NEW
RESIDENTIAL
GAS
LINE
NON-RESIDENTIJILL
13IGN
ADD
RETAINING
ElDEMOLISH
El
WALL
E]
EXCAVATE
FENCE
ALTER
F�
OR FILL
( x Ft.)
REPAIR
M
PRE -MOVE
INSP.
........ . ..........
SWIM
POOL
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I
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 lawn 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
relating to WorkmeWs CompIssation Insurance.
NOTE: Permit Ll t One Year (Except DE31013TIONS which
ri�
xhnil-b�comnleted Alneljoid �vn. -IN ]BUILDINGS shall be com-
NOTE: Applicant
to Plan Check Fee
This Permit covers work be = on private property ONLY.
Any construction on the ju I'lle (curlui, sidewalks, drivewayso
romquees, etc.) wi�req:jira stpurate permission.
5'
EXISTING STREET R/W .... ..... XT-
COMP. PLAN ST. R/W .......... FT.
[3 YES [] No
Plan Check No ............
VACANT SITE
E3 YES
I AN —Om ow
DEFICIENCY THIS PROPERTY
Valuation
13 YES C3 NO
Fee
BUILDING /-0 0 a
PLUMBING
HEAT & GAS LINE
FENCE
SIGN
RETAINING WALL
SWIM31ING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
No.
TOTAL AMOUNT DUE I
K
ATTENTION APPLICATION APPROVAL
T1139 PERMIT This application is not a permit until
AUTHORIZES
ONLY THE Signed by the Building Official or his Dep-
WORK NOTED uty; and fees are paid, and receipt is ac-
Imowledged in space provided.
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PH 6-ILI07
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