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[1A,1011NG- DEPART M ENT Applicant FM
. ERMIT APPLICATION 111111de 13eaVY 1011neg JOB ADDRESS
MpR NAME OF ;67.�_6 5
BUSINESS)
SIDE YARD SETBACK STREET SETI
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1JUPRONE NUMBER
HEIGHT BUM13ING
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TELEPHONE
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LICENSE NUM13ER CITY LICENSE NUMBER
Legal Description of Property (Show Below or Attach Four Copies)
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ALTER
REPAIR
RESIDENTIAL
Ef NON-RESIDENTIAL
IL
DDEMOLISH
EXCAVATE
M OR FILL
PRE -MOVE
INSP.
GAS
LINE
SIGN
RETAINING
F1 WALL
PENCE
( .......... x .......... Ft.)
SWIM
POOL
NUMB R OF
DWELLING
UNITS
ma,
-WANTURE OF WORK TO BE DONE
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13 YES
PERMIT,
NUMBER
t� I C3 YES
P17 �
a STREET R/W ..0A ... FT. DEFICIENCY THIS PROPERTY
PLAN ST. R/w LA .... FT. .... QL.rr.
ted on
Plan Check No ............. ... ...
R P US
BUILDING
ullding setbacks, ainitting streets) PLUMBING
t
HEAT & GAS LINE
PENCE
SIGN
RETAINING W AT -T
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 laws regu-
ATTENTION
lating construction; and to 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 Workmens Compensation Insurance.
AUTHORIZES
ONLY THE
NOTE: Permit Limit One Your (EXCept, DE51OLITIONS which
WORK NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com.
plated In onths.)
INSPECTION
IGNAT (OWNE)1qOR GENT) DATE SIGNED
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DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant iubject to Plan Check Fee
PR 6-1107
This permit covers work to be done on private property ONLY.
Any oemstruction oi3 the public domain (curbs, sidewalks, driveways,
nuLrqu6est ON,) will require separate permission.
not
Valuation
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VEM
C3 NO
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Fee I Receipt No.
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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-
knowledged in space provided.
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