690122.pdfPOSTED ON KROLL M" NO..
P ERMIT
BUILDING DEPAR TMENT
NUMBER
A pplicant Fill
PERMIT APPLICATION
Inside Heavy Lines
I
I
jog Ap-----
NAME (Olt NAMM OF BUSINESS)
e 2
tl 0
1
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J.
—
SIDE YARD SETBACK I STAEET BET33ACK
NAME
NAME
or
DNEW
RESIDENTIAL
GAS
LINE
NON-RESIDENTL"kL
ADD
SIGN
RETAINING
WALL
DEMOLISH
EXCAVATE
PENCE
ALTER
OR FILL
( x Ft.)
REPAIR
PRE -MOVE
INSP.
........ . ..........
swim
POOL
FUMBER OF STORIES
NU�R OF
DWELLINO
UNITS
e
EXISTING STREET R/W ........ ... FT.
COUP. PLAN ST. R/W ........... XT.
TYPE OF
[3 YES [:I NO
P -C
Plan Check
n C h c k
B I
BUILDING
N G
Al
P
PLUM]RING,
UK W N G
H E
HEAT & GAS LINE
A T A
F E N
PENCE
C E
S I
SIGN
G N
R E T C
RETAINING WALL
A INI
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION On 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 In doing the work authorized thereby, no person
will be employed In violation of the Labor Coda of the State of Washington
THIS ]PERMIT
relating to Workmen's Compensation Insurance.
AUTHORIZES
NOTE: Permit Limit One Year (Except DEMOLITIONS which
ONLY THE
WORK NOTED
shall be completed In ninety days; MOVED-ILN BUILDINGS shall be com-
pleted In six months.)
3IONAV= OR A NT) DATE78 N
�.4
INSPECTION
DEPARTMENT
ell
01
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Chech. Fee
P11 6-1107
This PernUt coven work to be done an private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marquees, etc.) will require separate permission.
1 1^
122
VACANT Tr—rE
13 YES El NO
VARLkNCE NUMBER pow
DEFICIENCY THIS PROPERTY
.......... In.
1:3 YES 13 NO
Valuation I Fee
No.
W00701�* EMN11
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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