690167.pdf—FO—BTEDoN KROLL MAP NO.'
NUMBER 690167
BUILDING DEPARTMENT Applicant F111 PERMIT
inside Heavy Lines jog ADDRE13B
PERMIT APPLICATION I I �- '7
NAME (OR NAME OF DUBIN C�_ 0 se
—IFID—EYARD SETBACK STREET SETBACK REAR YARD SETBAC
Uj, 0I kav%^
MAILING ADDRESS
LOT AREA �VACAN rAl
TELEPHONE NUMBER C] YES 0 NO
CITY L I — i
HEIGHT BUILDING AREA VARIANCE NU"MA 04
yvi 0 CL (P L-A 17-
NAME I I I
—f-L—OTPLAN APPROVED
ADDREBS
STREET F/�W Cy THIS PROPERTY
CITY �l TELEPHONE NUMBER EXISTING STREET n/W ............ FT- DEFICIEN
COUP. PLAN ST. R/W ............ FT. 0
REMARKS
NAME
A VVN
ADDRESS
N
CRECKE 13Y
o S
CITY TiG1,NFH_0Na; MUMBER
YVI 0 /J METER SIZE SERVICE SIZE CLEARANCE CHECKTr BY
CITY LICENSIG NUAIMBER
STATE LICENSE NUMBER
REMARKS
Legal Description of Property (Show Below or Attach Four Cople
-2- Lo+ (o TYPE CONNECTION VERIFIED BY
i;�, ri. L PrL (L Ad�a" 0 PERC. TEST PERMIT NUMBER
7mz r\)A
C) REMARKS
0
FIRE ZONE TYPE OF CONSTRUC71ON STREET IWIROVED
0 YES NO
ElNEW
RESIDENTIAL
_1
r
GAS
LINE
NON-RESIDENTIAL
SIGN
DEMOLISH
RETAINING
WALL
DALTER
EXCAVATE
OR FILL
FENCE
( x Ft.)
........ . ..........
REPAIR
R
PRE -MOVE
INSP.
SWIM
POOL
NUMBER OF STORIES
NUMBER OF
DWELLING
UNITS
0 YES 13 NO
Plan Check No ............ . .......
PROPOSED USE
BUILDING
PLAN_(IndFc_&te Building setbacij,—abutting streets)
PLUMBING
HEAT & GAS LINE
PENCE
t
SIGN
N
RETAINING WALL
13WIMI NO 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 regui-
AT17ENTION
laung 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
relating to Workman's COMPenfttl(M Insurance.
AUTHORIZES
ONLY T=
NOTE: Permit Limit One Year (Except DEMOLITIONS which
WORK NOTED
shall be completed in ninety days; MOVED -IN BUILDINGS shall be oom-
pleted In six months.)
— —
81 TURE(OWNER
INSPECTION
DEPARTMENT
0
- - -
Crry or
FAffli
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
PR 6-1107
Valuation
Fee
F-1
S_
No.
I 'A. so lvhq_� V
APPLICATION APPROVAL -
This application Is not a pem*At until
signed by the Building Official or his Dep-
uty; and fees are paid, and receipt is ac-
Imowledged in space provided.
. �:7 �
This permit covers work to be done on private property ONLY.
Aar 0anstruction on the public domain (curbs, sidewalks, driveways, rum
nuwquees, ate.) will require separate permission.