700170.pdfti
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BUILDING DEPARTMENT
PERMIT APPLICATION
1
Applicant Fill
Inside Heavy Lines
STED ON IMOLL MAP Diu.; PERMIT
NU1IBER
I 7onl7n
JOB ADDRESS
19770 FOP"- Ave. 0.
FNAMMOR 'NAME Or BUSINESS)
- —_ RE T SETBACK imA.R Y�D SETBACK
SIDE YARD SETBACK
WAILANU
;L44
USE ZONE CANT SITE
OT AREA [3 NO
I VARIANCIS NU:4bMn
0 CITY
1UMB11: FRI
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It
I_Z6
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1W
RESIDENTIAL
AS
CLINE
NEW
I
NON-RESIDENTI�Aj
SIGN
RETAINING
WALL
DEMOLISH
ALTER
EXCAVATE
OR FILL
FENCE
( ........ . x . ........ Ft.)
REPAIR
PRE -MOVE
INSP.
swim
POOL
NUMBER OF
DWELLING
UNITS
WTURE OF WORK TO BE DOPE
— - I
I
I..
STREET R/W ............ FT- DEFICIENCY THIS PROPERTY
COMP. PLAN ST. n/W ............ FT- . ............ FT.
0 YES tj NO
2L--
rian Check No .....................
BUILDING
PLUMBING
HEAT & GAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
I hereby acknowledge that I have read this application; that the In-
her eb y a k
en 9
formation given in correct; and that I am the owner, or the duly author-
'o rm , g v
th c
ized agent of the owner. 11 agree to comply with city and state laws regu-
I 2 ed age at 0
ATTENTION
loll
luting construction; and in doing the work authorized thereby, no person
cc I
I I ng an ruct
will be employed In violation of the Labor Code of the State of Washington
will be employed ir
THIS PERBUT
rel 139 to Workmen's Compensation Insurance.
all
AUTHORIZES
LNOTE: Permit Limit One Year (Except DEMOLITIONS which
E !erral
ONLY THE
WORK NOTED
ahall be completed In ninety days; MOVED -IN BUILDINGS shall be coin.
x I
pleted in six months.)
Ul 1,
GNATURE (OWNER OR AGEN9 DATE SIGNED
INSPECTION
DEPARTMENT
CITY OF
0
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
PR 6-1107
This FermIt covers work to be done on private property ONLY.
Any construction an the public domain (curb#, sidewalks, driveways,
marquees, etc.) will require separate permission.
[3 YES EJ No
Fee
MOO
0)2
0,;o I
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 ac-
knowledged in space provided.
2,2- — qiD
FILE
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