690116.pdf7 BUILDING DEPARTMENT Applicant Fill
�1! ICATION inside Heavy Lines
.fPERMIT APPL
NA(,V (OR NAME OF BUSIVEBB)
4
/ .9.3 / S-�
CITY
NAME
ADDRES
-al F—Y
CIT
1 Legal Description of Property (Show Below or
NEW RESIDENTIAL
GAS
LINE
NON-RESMENTIAL
13IGN
ADD
RETAINING
WALL
ALTER
DEMOLISH
EXCAVATE
OR FILL
El
FENCE
( x in.)
......... .........
El
REPAIR
PRE -MOVE
INSP.
El
SWIM
POOL
NUMBER OF
DWELLING
UNITS
[3 YES
BETBr_C_K
'ACS'
13 NO,
UMBER 04
;;ii_8!WNG__1 ST'REET R/W DEFICIENCY TMS PROPERTY
COMP. PLAN ST. R/W ....... .... FT.
[3 YES [3 NO
Plan Check No ...... . .........
PROPOSED UBE
BUILDING
-FL—OT PLAN (Indicate Building setbacks, abutting streets)
PLUMBING
HEAT & GAS LINE
PENCE
t
SIGN
N
RETAINING WALL
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 is 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-
ATTEI*MON
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
THIS PERMIT
relaung to WorkmeWx Compensation Insuranoe.
AUTHORIZES
NOTE: permit 11mit One Year (Except DEMOLITIONS which
ONLY THE
WORK NOTED
shall be completed in -ninety days; MOVEDAN BUILDINGS shall be oam-
pleted in six months.)
SI NATURE I[OWNErt Un AGENT) DATE SIGNED
INSPECTION
Y16
DEPARTMENT
CITY OF
EDMONDS
NOTE: Appli""t s4liect to Plan Check Fee
PR 6.1101
This permit coven work to be done on private property ONLY.
Any construction on the public domain (eurbs, sidewalks, driveways,
marquees, ate.) Will require separate permission.
13 YES E3 NO
Valuation I Fee
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-
Imowledged in space provided.
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