690267.pdfI
BUILDING DEPARTMENT
PERMIT APPLICATION
1
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S a"I -e
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P NUMBER C
I of Property (Show Below or
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Applicant Fill
Inside Heavy Lines
Fog
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0 NEW
RESIDENTIAL
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R
GAS
LINU
NON-RESIDENTIA
El
SIGN
ElADD
ElDEMOLISH
RETAINING
WALL
10/ALTER
EXCAVATE
FENCE
El
OR FILL
El
( x Ft.)
.......... ..........
REPAIR
PRE -MOVE
INSP.
1:1
swim
POOL
NUZdl3Nlt rip
DWELLING
UNITS
—5—N KROLL MAP NO.':PERMIT
69&26 7/
NUMBER
kRD SETBACK
STREET SETBACK__
13FAR YARD SETBACK
)NE
LOT AREA
VAUA141 OL
YES NO
A
nTTTr.nTWn
ARVIA
I VARIANCE ritlAUSElt
EXISTING I STREET R/W ............ FT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W ........... . FT. ............ FT-
NECT10N
FIRE
0 YES 0 NO
REMARKS
Plan Check No .....................
Z
0
BUILDING
5.
PROPOSED USE
PLUMBING(,:�
PLOT PLAN (Indicate Building setbacks, abutting streets)
HEAT & GAS LINE
PENCE
I
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
I hereby acknowledgo that I have read this application; that the In-
I hereby
formation given Is correct; and that I am the owner, or the duly author-
'a rmat 'on give
Ized agent of the owner. I agree to comply with city and state laws regu-
'zed ag on' of I
ATTENTION
latIng construction; and In doing the work authorized thereby, no person
Is. Ing constru
will be employed In violation of the Labor Code of the State of Washington
will be employ(
THIS PERMIT
relating to Workmen's Compensation. Insurance.
AUTHORIZES
ONLY THE
LZTE: Pei'qrmit Limit One Year (Except DE51OLITIONS which
WORK NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted in six months.)
, (
SIGNATURE (OWNER Oft AGENT) DATE S GNED
TURL
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
PR 6.1107
This Permit coven work to be done on private property ONLY.
Any construction on the public domain (curbs. sidewalks, driveways,
marquees, etc.) will require nepwate permission.
Ej YES [:] NO
Valuation I Fee
1 00 1(5�516.
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-
Imowledged in space provided.
Q44A
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