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PERMIT APPLICATION I 1mA_1d0p'ft:vyjM"
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TELEPHONE NUMBER
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W _XROLL MAP NO.'. PERMIT
//_5� 1 1 NUMBER 690012
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.26 -10 �a--77
D SETBACK STRE T SETBACK PgZr�YARDSETB
V CANT SITE
_L 02T —ALA _2_���
't .2 orz 1 0 YES 0 NO
42 71 IP I
��REET R/W .14.0.117. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W .6.0.XT.
on Standard Drawing #103.
METER SIZE SERVICE
STATE LJCENSE NUMBER CITY
jAL;NNsE NUMBER
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;?2 -3
REMARKS
Legal Description of property (unow zeio;W or —Attach Four copies)
TYPE CONNECTION
Z
0
PERO. TEST
Q
REMARKS
FIRE ZONE E ol
TYP
SP INSPECTOR
RESIDE NTLJLL
GAS
LINE
[I YES �)kNO
PLAN CHECqD BY
NEW
Hl
(8
NON-R
10:1 SIGN
RETAINING
WALL
REMARKS
DEMOLISH
No
E] ALTER
EXCAVATE
OR FILL
PENCE
El ( ........ . X .......... Ft.)
octcupanc
REPAIR
PRE -MOVE
F1 INSP.
SWIM
EIPOOL
inntallati
_P
I NUMBER OT
DWELLING
UNITS
NATURE OF WORK TO 130�7733
A-It-71"I
jo/
Y(5�g c " ro /26, IF -
Plan Check No ....................
PROPOSED UBE
BUtLDING
PLOT PLAN (Indicate BuIldia-g—isetbacks. abutting streeta)
PLUMBING
HEAT & GAB LINE
PENCE
t
BIGN
N
RETAINING WALL
SWIMMING POOL
OLITION
pRE-MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
I hereby Lcknowledge that I have read this application; that the In-
formation given Is correct; and that I am the owmer, or the duly allthOr-
Ized agent of tile owner. I agree to comply with city and Biala laws regu-
ATTENTION
lating confitrUCUOn; end in doing the work authorized thereby, no person
will be employed to Violation Of the Labor Code of the State of Washington
THIS PE113UT
relating to Workmen's Compensation Insurance.
AUTHORIZES
ONLY THE
NOTE: Permit Limit One Year (Except DE5101ATIONS which
WORK NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted in six months.)
INSPECTION
SIGNATU R& (0 FR OR �A_G�ENTI
DEPARTMENT
EZ
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
Fla 6-1107
This permit Cavan work to be done an private property ONLY.
Any construction an the public domain (carbs, sidewalks, driveways,
conrquees. etc.) will require separate permission.
Valuation
L,�
[3 YES [3 NO
1-1
Fee
6-0
AE
No.
_0_37 ro-
APPLICATION APPROVAI
This application is not a permit until
signed by the Building official or Wo Dep-
uty; and fees are paid, and receipt is ac-
knowledged in space provided.
DIRECTOR'S SIGN
FILE
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