680419.pdfa
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U
BUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION Inside Heavy Lines
NAMX,(OR NAME 0jr/51184fESO)
ra
n
Z
I KROLL MAP No.:
r
2
Z6 G 11
USE-=
TY LEPHONE NUMBEC-- 13 YES
VARIAN
ej IiE1ORf__ _TBUILDIrIff AREA ON NUMIJ11"I
or
RESIDENTIA
GAS
LINE
NEW
NON-RERIDE TIAL
F I
SIGN
ADD
RETAINING
WALL
DEMOLISH
ALTER
EXCAVATE
OR FTLI,
FENCE
( x Ft.)
......... .........
REPAIR
PRE -MOVE
INSP.
SWIM
POOL
ES
NUMBER OF
DWELLING
I
UNITS
NATURE OF WONCqO B
.YC�E
EN38TING STREET R/W ........... FT -
COUP. PLAN ST. R/W .......... Irr.
0 YES 13 NO
Plan Check No ........
BUILDING
BU DING
PLUMBING
PL ":G
BE T & GAB LINE
HEAT & GAS LINE
FENCE
FENCE
SIGN
SIGN
RETAINING WALL
R T 0 WALL
s wimznNo
= POOL
DEMOLITION
PRE -MOVE IN SPECT ION
EXCAVATION OR FILL
EX 7
F
TOTAL MOUNT
TOTAL AMOUNT DUE
I hereby acknowledge that I have read Ugs ApPllc&Ucn; Mat 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
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
TUN PERMIT
relating to WorkmeWs Compensation Insurance.
1
AUTHORIZES
NOTE: Permit Umit One Year (Except DEMOLITIONS which
ONLY TI[E
WORK NOTED
mball be completed in ninety days; MOVED -IN BUILDINGS shalt be com-
pleted In mix months.) 7
A
_81G7NRE (OWNER On Aq;NT) TO SIGN ED A
rNSPECTI ON
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Subject to Platt Check Fee
rn 6-1107
This permit covers work to be done on private property ONLY.
Any construction an the public domain (curbs, sidewalks, driveways,
marqucas, etc.) will require separate permission.
DEFICIENCY THIS PROPERTY
V
11] YES 13 NO
Fee
a.0
APPLICATION APPROVAL
No.
This 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.
FILE
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