680237.pdfFrOSTED ON KROLL MAP N5
[BUILDING DEPARTMENT Applicant FIII
PE
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PERMIT APPLICATION
E NAME OF BUSINESS)
NAM OR
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VULING ADDRESS
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31TY TELEPHONE NUMBER
1'-743 - ol4o
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OF
OF
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RESIDENTIAL
NEW
GAS
LINE
[E]
NON-RESMENTIAL
ADD
SIGN
- TAINING
R
WALL
DEMOLISH
EXCAVATE
FENCE
ALTER
OR FILL
( x Ft.)
REPAIR -
PRE -MOVE
INSP.
El
.......... ........
SWIM
POOL
MMBER OF STORIES
NUMBER OF
DWELLING
f
UNITS
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 lawn regu-
lating construction, and In doing the work authorized thereby, no person
will be employed in violation of the Labor Coda of the State of Washington
relating to Workmans Compensation Insurance.
NOTE: Permit Limit One Your (Except DEMOLITIONS which
shall be c . omplated in ninety days; MOVED -IN BUILDINGS shall be com-
pleted In oil months.)
EXISTING STREET R/W ........... JPT.
COMP. PLAN ST. R/W ........... J".
[3 YES [3 NO
PERMIT
NUMB= 680237
13 YES
(3 NO
DEFICIENCY THIS PROPERTY
rhR
STREET IMPROVED
13 YES [3 I -TO
ROUP
I
Plan Check
Valuation
Fee
Receipt No.
BUILDING
S--0
PLUMBING
HEAT & GAS LINE
PENCE
SIGN
RETAINING WALL
SWIM39NG POOL
DEMOLITION
PRE,MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
ATTENTI[ON
TIM PERMIT
AUTHORXZES
ONLY THE
WORK NOTED
APPLICATION APPROV
TMs application Is not a permit until
signed by the Building Official or his Dep-
uty; and fees are paid, and receipt Is ac-
knowledged in space provided.
INSPECTION
fATURE (OWNER OR AGE DATE SIGNED DEPARTMENT
)t&L'V' 1 �� Ti 3 t (a CITY OF
�j EDMONDS
NOTE: Applicant Subject to Plan Check Fee PR 6-1107
_jgg Permit covers work to be done On Private Property ONLY -
Any construction an the public domain (curbs# sidewalkes drlv&waYsp
mwquw,4 etc.) will require separate perrolmolon.
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