680408.pdfBUILDING DEPARTMENT ApplIcant FM
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rtKMI1 APPLULAIIUM
NAME (OR NAME OF BUSINESS)
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MAILING ADDRESS
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CITY
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'YE—LEPHONE NUMB
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NEW SIDENTIAL
GAS
LINE
1:1 NON-RESIDENTIAL
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ADD
SIGN
RETAINING
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WALL
DEMOLISH
EXCAVATE
PENCE
ALTER
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Ft.)
OR FILL
( ........ . x . ........
REPAIR -1 PRE -MOVE
1:1 INSP.
swim
POOL
NUMBNR OF STORIES
NUMBER OF
DWELLING
UNITS
NATURE OF WORK TO BE DONE
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PROPOSED USE
_fL_CFT TPLAN (Indicate Building setbacks, abutting streets)
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I hereby acknowledge that I have read thin 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-
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 Workmens Compensation Insurance.
NOTE: Permit Limit One Year (Except DEMOLITIONS which
shall be completed in ninety days; MOVED -IN BUILDINGS shall be corn-
pleted In six months.)
Flo -NATURE (OWN OR �,PENT) DATE S1PNE1y
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NOTE: ApPlicant Subject to Plan Check Fee
This Permit coven work to be done on private PrOPWY ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
nterquees, etc.) will require separate Permission.
I
I ON KROLL MAP NO.: PERMIT
0 NUMBER 680408
DRESS
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ARD SETBACK STREET SETBACK REAR YARD UNWMA'
1 - 1 125- 1 . I 'a S I n ;..,d
all I keYES 0 NO
- - ____ __1 - -
EXISTING STREET R/W FT. DEFICIENCY Tine PROPERTY
COMP. PLAN ST. Rjw 10.Imr. .... A .... IV.
indicated on Standard Drawing #103.
VA
�414*01
FtUCTION 13THP-ET IMFROVJ
0� R/ [] YES 13 NO
0 YES
Plan Check No ........
BUILDING
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PLUMBING
HEAT & GAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
1!
TOTAL AMOUNT DUE
/0.;t S 0
AT=NTION
APPLICATION APPROVAL
THIS PERMIT
TWs application is not a permit until
AUTUOIUZES
signed by the Building Official or his Dep-
ONLY THE
WORK NOTED
uty; and fees are paid, and receipt Is ac-
knowledged in space provided.
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
DATE
PR 6-1107
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