680182.pdf0
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BUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION inside Heavy Lines
NAME (OR NAME OF BUSINESS)
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MAILING ADDRESS
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CITY TELEPHONE NUMBER
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DITY
BTATE LICENSE NUMBEI
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TELEPHONE NUMBMK
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CITY LICENSE NU
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RESIDENTIAL
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GAS
LINE
NEW
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NON-RESIDENTIAL
SIGN
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RETAINING
F1
WALL
0 ALTER
DEMOLISH
EXCAVATE
OR FILL
FENCE
( X n.)
.......... ..........
REPAIR
PRE -MOVE
INSP.
SWIM
POOL
FUMBER OF STORIES
I NUMBER OF
DWELLING
UNITS
4 .04 t 2347-AU 0
�OaTED ON KROLL MAP NO.: PERMIT
NUMBER 680182
OB ADDRESS
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USE Z035 LOT AREA
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[I[EIGHT BUILDING AREA,
VA NCE NUMBER
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PLOT PLAN APPROVED
STREET R/W
EXISTING STREET R/W ... ....... XT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W .... ....... M. ........... 1".
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CHECKED By
METER SIZE I SERVICE SIZE I CLEARANCE
ICHECKED BY
REMARKS
TYPE CONNECTION I
VERIFIED BY
PERO. TEST
PERMIT NUMBER
REMARKS
FIRM ZONE TYPE OF CONSTRUCTION STREET IMPROVED
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-OPLTLM INSPECTOR RE
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0 YES 0
OCCUPANCY GROUP
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P LAN CHECKED BY
REMArJW
Valuation
Fee
Receipt N o.
Plan Check No .....................
BUILDING
PLUMBING
HEAT & GAS LINE
PENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
_FTOTAL
EXCAVATION OR FILL
AMOUNT DUE
I hereby acknowledge that I have read this application; that the In-
d other"
formation given is correct; and that 7 am the owner, or the duly author.
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Ized agent of the owner. I agree to ccmply with city and state Iowa regu-
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ATTENTION
ob Y, no P' rBou
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 PERMIT
relating to Workmen's Compensation Insurance.
AUTHORIZES
ONLY THE
NOTE: Permit Limit One Year (Except DEMOLITIONS which
WORK NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
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RON URE (OWNER YR DATE SIGNE
INSPECTION
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DEPARTMENT
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CITY OF
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EDMONDS
NOTE: Applicant Subject to Plan Check Fee
Pa 6-1107
Thin Permit covers work to be done on Private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
conrquees, etc.) will require separate perniJoslon.
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APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or Me Dep-
uty; and fees are paid, and receipt is ac-
knowledged in space provided.
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