690431.pdfa
BUILDING DEPAKI cril Applicant Fill
Inside Heavy Lines _5
PERMIT APPLICATION
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NAME OF B
NAME (0
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NAME
ADDRESS
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CITY
NAME
A
Z
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TZ LICENSE; -NUMBEN CITY LICENSE 111M
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ni nPnerintion of FronerLY-tbnOW IJ01OW or Attach Four Coph
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0 NEW RESIDENTIAL
El
AS
CLINE
NON-RESIDENTIAL
El
SIGN
ElADD
RETAINING
ElDEMOLISH
D
WALL
ALTER
F]
EXCAVATE
OR FILL
FENCE
( .......... x .......... Ft.)
REPAIR
PRE -MOVE
INSP.
SWIM
POOL
NUMBER OF
DWELLING
UNITS
,ITATURE OF WORK TO BE DONE 0�
eAl-CrMLL
;vOiji
EXISTING STREET R/W ............ FT.
COUP. PLAN ST. R/W ............ FT.
FIRE
C] YES [3 NO
Plan Check No .....................
BUILDING
PLUMBING
';i�AA GAS LINE
4N C E;
PENCE:
Ei
SIGN
H G N
tRETAINING
WALL
N
WIM3nNG POOL
S Wt I
rEXCAVATION
L
EMOLITION
D EM
.1 r N
PRE -MOVE INSPECTIO,
P -1 OV
OR FILL
XC V TION On
TOTAL AMOUNT DUE
I hereby acknowledge that I have read thin 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 Code of the State of Washington
THIS PERMIT
relating to Workmen's Compensation Insurance.
AUTHORIZES
ONLY THE
NOTE: Permit Limit One Year (Except DEMOLITIONS which
WORK NOTED
&hall be completed in ninety days; MOVED -IN BUILDINGS shall be com-
pleted In nix months.) A
—
RIGNATURE (OWN, R AGENT)
F�y
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
NOTE: AppliVit Subject to Plan Check Fee
PR 6-1107
This Fervalt coven work to be done on private preperty ONLY.
Any construction on the public domain (eurbs, sidewalks, driveways,
marquees. etc.) wul require separate permission.
PERMIT
NUMBER
r 5-&)
VACANT SITE
14
[3 YES [3 NO 4
iE3ZXB I
VARIANCE NUMBER j a,
DEFICIENCY THIS PROPERTY
a
Z
0 YES [3 No
Fee I Receipt No.
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 ae-
Imowledged in space provided.
I / V -�
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