680121.pdft I
BUILDING DEPARTMENT Applicant F111
PERMIT APPLICAI Inside Heavy Lines
MAILING'ADDII
0
0
TELEPHONEIYUMBER
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NAME
ADDRESS
CITY
TELEPHONE NUMBER
NAME
IIDDRE138
CITY
TELEPHONE NUMB ER
STATE LICENSE NUMBER
7
ITY LICENSE NUMBER
Legal Description Of Property (Show Below or Attach Four Copies)
Z
14
GAS
RESIDENTIAL LINE
El NEW
NON-RESIDENTIAL D SIGN
ADD RETAINING
WALL
0
DEMOLISH
0 EXCAVATE FENCE
ALTER
D OR FILL ( ........ . x ..........
ED REPAIR PRE -MOVE swim
El- INSP. POOL
NUMBER OF
DWELLING
UNITS
P NO.:
A0 � S I
EXISTING STREET R/W ..... . . ... FT.
COUP. PLAN ST. R/W ........ .. XT.
0 YES
TYPE OF
[3 NO
Plan Check No ................ . ...
PROPOSED USE
BUILDING
PLOT PLAN (Indicate Building setbacks, agutting atmets)
PLUMBING
HEAT & GAS LINE
PENCE
t
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 owmer, or the duly author-
Ized agent of the owner. I agree to comply with City and state laws rCgU-
ATMNTION
lating construction; and In doing the work authorized thereby, no person
will be empjoyed In violation of the Labor Code of the State of Washington
THIS PERMIT
relating to Workmen's Compensation Insurance.
AUTIIOR[ZE8
ONLY THE
NOTE: Permit Limit One Year (Except DE151OLITIONS which
WORK NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be Coca.
plated In six months.)
SWVATURF. (OWNER OR AGENT) DATE SIGNED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Cbeck Fcc
Pit 6-1107
This Permit covers work to be done on private property ONLY.
Any construction on the public donnain (curbs# oldewalkas drIvemays.
marquees, ate.) will require sapamte permission.
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PERMIT
NUMBER
ACK REAR YARD BETE
VACART SITE
[3 YES [3 NO
DEFICIENCY THIS PROPERTY
........... FT.
Valuation
[] YES 13 NO
Fee
0
1-
8
Z
W
W__ 11WW1011111
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-
Imowledged in space provided,
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0
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