680124.pdfBUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION Inside Heavy Lines —j
NAMM (OR NAME OF BUSINESS)
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CITY wiu"MLONE NUMBER
NAME
[3 ON KROLL MAP NO.: PERMIT
NUMBER
680124
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-.20 I
rARD SETBACK
-
STREET SETBACK
REAR YARD SETBACK
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WNE
i,u,r AREA
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YES NO Z
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BUILDING AREA
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VARIANCE VUMBEIC ILI
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EXISTING. STREET R/W ........ .. YT. DEFICIENCY THIS PROPERTY
COUP. PLAN ST. R/W ........ .. XT.
STATE LICENSE NUMBER Orl-JI LILUNNbju "��n tt
2A Y4
Legal Description of Property (Show Below or Attach Four Copies)
__TFrPM CONNECTION
e� PERC. TEST
a
2_';tESIDENTIAL
El
GAS YES
LIND PLAN
1:1 NO
SIGN I
ADD
E] DEMOLISH
RETAINING REMAJ
WALL
ALTER
EXCAVATE
M
FENCE
Frt.
OR FILL
( ... ...... X .. .......
REPAIR
PRE -MOVE
INSP.
SWIM
POOL
NUMBER OF STORIES
NUMBER or
DWELLING
UNITS
NATURE OF WORK TO BE DONE
Plan Check No ............ . .......
PROPOSED USE
BUILDING
PLOT PLAN (Indicate Building setbacks, abutting streets)
PLUMBING
S
BEAT & GAS LINE
PENCE
SIGN
N
RETAINING WALL
X
*4-
swimlidaNG POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
I hereby acknowledge that I havo read this application; that the In-
formation given In correct: and that I ara the owner, or the duly author-
ized agent of the owner. I agree to comply with city and state laws regu-
ATTENTION
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
THIS PEMIIT
relating to Workmen's Compensation Insurance.
AUTIIOIUZES
NOTE: Permit Mmit One Year (Except DE31OLITIONS which
ONLY THE
WORK NOTED
shall be completed In ninety days; MOVIED-IN BUILDINGS shall be com-
pleted lit mix months.)
-61-GNATURE (OWNER Oft AGENT)
DATE SIGNED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
PR 0-1107
This Ferialt covers work to be done an private property ONLY.
Any oonstraction on the public domain (curbs, sidewalks, drivenvays,
MjLrqumx. etc.) will require separate permission.
[3 YES [3 No
Fee
I Q E
.46 i
I
No.
I & 5-1!ro IN -3 � /)I
APPLICATION APPROVAL —
This application is not a pernilt until
signed by the Building Official or his Dep-
uty; and fees are paid, and receipt is ac-
Imowledged in space providecL
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