680239.pdf I ....... I—— 1 � 11 - __..__________ 'I - . _
I
POSTED ON KROLL M,
BUILDING DEPARTMENT Applicant Fill
s
PERMIT APPLICATION inside Heavy Lines JOB ADDRESS
NAMEJUMI�NAXW OF 15U rleila —
c7_4 SIDE YARD SETBACK
ADD 88
-7 USE ZONE
V
or
V,
RESIDENTIAL
GAS
LINE
NEW
NON-RESMENTIAL
13IGN
RRETAINING
WALL
0
ALTER
El
DEMOLISH
EXCAVATE
OR FILL
FENCE
( ........ _x .......... Ft.)
REPAIR
PRE -MOVE
INSP.
SWIM
POOL
RIMBER OF STORIES
NUMBER OF
DWELLING
UNITS
PERMIT
NUMBER
YES 13 NO
EXISTING STREET R/W .... ....... FT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W ........... FT. ....... .... 17.
0 YES [] NO
10M,
Plan Check No ..................
PROPOSED USE
BUILDING
Q
PLOT PLAN (Indicate Building sethmckfi, abutting streets)
PLUM=NG
HEAT & GAS LINE
FENCE
t
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
I hereby acknowledge that I have read this application; that the In-
formation given In 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-
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 PER1111T
relating to WorkmeWe Compensation Insurance.
AUTHORIZES
ONLY THE
NOTE: Permit Umit One Year (Except DEMOLITIONS which
JVORK NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted in six months.)
ATURE (U�WINEAOlt AGENT)
DATE SIGNED
INSPECTION
DEPARTMENT
CITY OF
OMM
EDMUNDS
=NTIE: Applicant Subject to Plan Check Fee
Pit 0-1107
Thin Permit coven work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
mrxQuees, etc.) will require separate permission.
Z
N
BY
0 YES [3 No
Valuation
FIe-o-
- 1=;l 4--v 1
APPLICATION APPROVAL
This application is not a pern-dt until
Signed by the Building off Icial or his Dep-
uty; and fees are paid, and receipt is ac-
Imowledged in space provided.
-3
FUM