690120.pdf9
I
BUILDING DEPARTMENT Applicant Fill
PERMIT APPLICATION Inside Heavy Lines
OR or B
/ 409
/Z , ; X -, -
MAILING ADDRESS
INY 1Y /7&-7-k
-.4
aGENSE NUMBER
3 — dq/
fl
ow or
VA
/ 2_.a—S-91
Ell"NEW
RESIDENTIA
0
GAS
LINE
E]
I
NON -RESIDE NTIAL
M
SIGN
__
DEMOLISH
RETAINING
WALL
EXCAVATE
FENCE
ALTER
OR FILL
PRE -MOVE
( ........ . x . ........ Ft.)
swim
REPAIR
INSP.
Pool,
NUMBER OF
DWEL&MG
UNITS
I ON KROLL MAP NO.:
PERMIT
NUMBER
I .
690120
DRESS
A
ARD SETBACK
STREET SETBACK
REAR YARD SETBACK
LOT AREA
VACANT SITE
E3 YES E3 No
I N
1 BUTT ING AREA
VARIANCE NU:H7E_Rjj
EXISTING-STREEM R/W .......... FT. DEFICIENCY THIS PROPERTY
CGMP. PLAN ST. .......... FT.
TYPE
13 YES 13 NO
Plan Check
PROPOSED US9__
BUILDING
PLOT PLAN (Indicate Building setbacks, abutting streets)
PLUMBING
HEAT & GAS LINE
PENCE
t
SION
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
I hereby acknowledge that I have read this application; Mat the in-
formation given to 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
ATTENTION
will be employed In violation of the Labor Code of the State of Washington
THIS PERMIT
relating orkman's Cc m L 'murance'
AUTHORIZES
.-PT
N01t: P�rmit Limit ear ( scept DEMOLITIONS which
PI'WOVEZi
ONLY THE
WORK NOTED
0=4t ninety BUILDINGS shall be com-
=t Alce /M n
INSPE CTION
IIGN;A (0 ER AGENT DATE SIGNED
DEPARTMENT
'Pt'
CITY OF
EDMONDS
ATE: Applicant Subject to Plan Check Fee
ra 6-1107
This Fellult Covers WOrK to Do done on pnvase proper;y un�x.
Any construction on the public domaln (curbs, sidewalks, driveways,
marquees, so.) will requira separate permission.
goo
00
C3 YES 0 NO
.3, 0 0 IM (�
APPLICATION APPROVAL
This application Is not a permit until
signed by the Building Official or Ids Dep-
uty; and fees are paid, and receipt is ac-
knowledged in space provided.
DL�IiEqroll'S SIGrJATFRE
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