680388.pdfBUILDING DEPARTMENT ApplicantFill
PERMIT APPLICATION Inside Heavy Lines
NAM (OR NAME OF BUSINESS)
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11111 Legal viepeription of Property (Show Below or AttacliL Four Copies)
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POSTED ON KROLL MAP NO.:
PERMIT
NUMBER 680388
JOB ADDRESS
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SIDE YARD SETBACK
STREET SETBACK
REAR YARD SETBACK
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USE ZONE
LOT AREA
VACANT luria
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1 0 YES 51_N�o
NEW
RESIDENTIAL
GAS
LINE
NON-RESIDENTIAL
ADD
SIGN
ElDEMOLISH
RETAINING
WALL
EXCAVATE
FENCE
ALTER
n
OR FILL
( x Ft.)
E] REPAIR
El
PRE -MOVE
INSP.
Ej
........ . ..........
swim
POOL
NUM13ER or
DWELLING
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STREET-27W
EXISTING STREET R/W ............ FT. DEFICIENCY THIS PROPERTY
COUP. PLAN ST. R/W ........... XT. ............ in.
0 YES [:I NO
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P "AN 711
4
Plait Check No ............. .......
PROPOSED USE
BUILDING
PLUMBING
PLOT PLAN (Indicate Building setbacks, abutting streets)
HEAT & GAS LINE
FENCE
t
SIGN
N
RETAINING WALL
SWIM NG 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 laws regu.
ATTENTION
laung 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 PERMIT
relating to Workmen's Compensation Insurance.
AUTHORIZES
NOTE: Permit Limit One Year (Except DE51OLITIONS which
ONLY TEW.
WORK NOTED
shall be Completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted lit six months.)
I)ONXTURE (OWNER OR A T)
DATE SIGNED
INSPECTION
FG,
DEPARTMENT
Lli�j
Cat, e, t I&
g
CITY OF
/
ELPITALONDS
NOTE: Applicant Subject to Plats Check�4ee
PH 0-1107
This Penalt covers work to be done onprivate property ONLY.
Any construction an the public domain (curbsp sidowalksp driveways$
maNueeg, etc.) will require separate permission.
Valuation
M
STREET I.MPROV:
[] YES El NO
Fee
I
No.
1 15 /V-I 0�-
APPLICATION APPROVAL
This application is not a permit until
signed by the Building Official or his Dep-
uty; and fees are paid, and receipt Is ac-
knowIedged in space provided.
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