680192.pdfPOSTED ON KROLL MAP NO.: PERMIT
BUILDING DEPARTMENT Applicant F111 NUMBER
4
! PERMIT APPLICATION Inside Heavy Lines JOB ADDRESS
OR
1�1 — P4
ME (OR NAME OF BUSINESS)
NA
ADDRE138
4 . Aa— 5?.e�
CITY T!;EPHONE - NITM
NAME
Cd
ADDRESS
5ee 6-3 V
CITY TELEPHONE vUMBI
Z
I R GAB
NEW RESIDENTIAL LINE
I M NON-RESIDENTIAL I El SIGN
ADD RETAINING
DDEMOLISH WALL
ALTER EXCAVATE FENCE
OR FILL ( .......... x .......... Ft.)
REPAIR PRE -MOVE swim
INSP. POOL
DWELLING
UNITS
PROPOSED US —
I hereby acknowledge that I have read thin application; that the In-
formation given Is correct, that I am the owner, or the duly author-
ized agent of the own I ree to comply with city and state laws regu-
'wo
latIng conztructlon, In doing the work authorized thereby, no person
Uon
will be employfd of the Labor Code of the State of Washington
olati )f
olati
relating IN,, eu��s pensation Insurance.
NOTEJPe�i i t U it One Year (Exc:ept Dl�'MOIJTIONS which
r
sbaii hp om e ed In nety days; _MOVED-IWBUILDl[NG8 shall be com.
NOTE: Applicant Subject to Plan Check Fee
This Permit coven Work to be done on private property ONLY.
Any construction on the public domaln (curbs, sidewalkst drivewayst
marquees, etc.) will reQuire separate permission.
11TO
EXISTING STREET R/W ............ FT.
COUP. PLAN ST. R/W ............ FT.
FIRE ZONE I TYPE OF
0 YES 0 NO
Plan Check No ............
1 *10 9 0) 03 4ZPe'
HEAT & GAS LINE
FENCE
SIGN
RETAINING WALL
SWIM NO POOL
10*H-)_AQ0 "01
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
ATMNTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
PR 0-1101
13 YES
DEFICIENCY THIS PROPERTY
............ 167r.
YES [3 NO
Fee
F.
I
APPLICATION APPROVAL T t
This application Is not a permit until J
signed by the Building Official or his Dep-
uty; and fees are paid, and receipt is ac-
Imowledged in space provided.
PIV
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