680222.pdfBUILDING DEPARTMENT Applicant M
PERMIT APPLICATION Inside Heavy Lines
NAME (OR NAME OF 4USINE88
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MAILING ADDRESS
ID
CITY TELEPHONE NUMBER
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NAME
7XUD—RESS
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TELEPHONE NUMBER
NAME
CIT7 TI�PEPHONE NUMBER
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0 41-7 7 4o 0
STATE LICE1413E NUMBER CITY LIuNL4151fi NUMBER
2,2,3 —6 2- - 3 S�5 4)
Legal Description of Property (Show Below or Attach Four Copies)
a N - C F /Y 4r,
04c 7-WP 2.7 A4 174A(6re #,�,Wlj
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F1 NEW
RESIDENTIAL
E]
ASE
ZIN
NON-RESIDENTIAL
F�
SIGN
UNG
—_ .—ALI
ADD
ALTER
DEMOLISH
EXCAVATE
OR FILL
FENCE
( X Ft.)
REPAIR
PRE -MOVE
INSP.
.......... ..........
SWIM
POOL
DWELLING
UNITS
iNE
2-
t
N
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 laws 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 Workman's Compensation Insurance.
NOTE: Permit rimit One Year (Except DEMOLITIONS which
aball be completed in ninety days; MOVED -IN BUILDINGS shall be com-
pleted in six months.)
A-(
NOTE: Applicant Siibject to P(an Check Fee
This Permit covers work to be done on privRta Property ONLY.
Any construction an the public domain (curbs, sidewalks, driveways,
marquees, etc.) will require separste permission.
'Yh *�
EXISTING STREET R/W ............ FT.
COMP. PLAN ST. R/W ............ FT.
ZONE
0 YES
E] NO
PERMIT
NUMBER
(j YE13
4,r?)
SETBACK
a
(3 NO
[UMBER
DEFICIENCY THIS PROPERTY
0 YES 0 NO
Maximum 1 )� connection to sanitary sewer
requireds.
Plan Check No ............
BUILDING
PLUMBING
HEAT & GAS LINE
PENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
ATMNTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDIVIONDS
PH 6-1107
Valuation
OR.
Fee
1.01
Z
N
I
to
Receipt No.
APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or his Dep-
uty; and f ees are paid, and receipt is ac-
lmowledged in Space provided.
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