680317.pdfT �4
BUILDING DEPARTMENT
r M11 N AppUcant Fill
Inside Heavy Lines
PERMIT APPLICATIO
E NAMIL (oft NAME Oil BUSINESS)
C ;7, a,�-z J-4 -VIVI
MAILING ADDREtJS
LEPHONE NUMBER
'NAME
ADDRESS
CITY TELEPHONE NUMBER
NAM
ADDRESS
CITY TELEPHONE NUMBER
STATE LICENSE NUMBER CITY LICENSE NUMBER
Legal De art tj of Property (Show� �Belor ttach FqRF Copies)
t7n!
V
U
41
GAS
F] NEW RESIDENTIAL LINE
NON-RESIDENTL&L SIGN
ElADD RETAINING
0 DEMOLISH WALL
ALTER EXCAVATE FENCE
E� OR FILL ( .......... x ..........
REPAIR PRE -MOVE swim
R INSP. POOL
DWELLING
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 duty 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 Workmen's Compensation Insurance.
NOTE: Permit Limit One Year (Except DEMOLITIONS which
shall be completed In ninety days; BIOVED-IN BUILDINGS shall be com-
plated In six months.)
?R AGENT) DATE SIGN
6e,
NOTE: Applicant Subjcct to Plan Chcck Fce
This Permit cov rs work 10 be done ou private Property ONLY.
Any construction on the public domain (curb$, sidewalks, driveways,
marquees, etc.) will require separate permission.
IOSTED ON KROLL MAP NO.:
PERMIT
680317
NUMBER
OB ADDRESS P. N04
"L d"?) � 6
=ETACK
IIDE YARD SETBACK STREET SETBACK IWM, RMM SETBACK
USE ZONE LOT AREA VACANT SITIG
YES NO
[MIGHT TU—ILDING AREA VARIANCE NUMBER
PLOT PEK—NAPPROVED
STREET RIW
EXISTING STREET R/W ............ FT- DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W ........... XT. ............ 17.
0
REMARKS
Z
C RECKED BY
METER SIZE SERVICE SIZE CLEARANCE
CHECKED BY
C9
REMARKS
TYPE CONNECTION
VERIFIED BY
PERO. TEST
PERMIT NUMBER
REMARKS
FIRE ZONE TYPE OF CONSTRUCTION
STREET IMPROVE
[:] YES NO
SPECIAL INSPECTOR REQUIRED
OCCUPANCY GROUP
[3 YES 0
1
PLAN CHECKED By
Valuation I Fee I Receipt No.
Plan Check No .....................
BUILDING
PLUMBING
HEAT & GAS LINE
PENCE
SIGN
RETAINn-TG WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL A31OUNT DUE I
ATTIDNTION APPLICATION APPROVAL
THIS PERMIT This application is not a permit until
AUTHORIZES signed by the Building Official or his Dep-
ONLY THE
WORK NOTED uty; and fees are paid, and receipt is ac-
Imowledged in space provided.
INSPECTION D ECTOR'S — BIG U E
DEPARTMENT V4 7
CITY OF DA'M
EDMONDS
PR 6-1107
FILE