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POST' - D ON OLL MAP NO.; PERMIT
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BUILDING DEPARTMENT Applicant Fill NUMBER
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PERMIT APPLICATION -bib
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TELEPHONE NUMBER
STATE LICENSE NUMBER
CITY LICENSE NUMBER
Legal Description of Property (Show Below or Attach Four Copies)
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iTHEET R/W
EXISTING STREET R/W ............ FT. eEFICIENCY THIS PROPERTY
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REMARKS
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METER 81 ICLEARANCE ICRECKED BY
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Typ VCNECTION VERIFIED BY
PERO. TEST PERMIT NUMBER
REMARKS 9
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NEW RESIDENTIAL 71 LINE PLAN CHECKED BY
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NATURE OF WORK TO BE DONE Valuation Fee Receipt No.
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BUILDING
PROPOSED USE
PLUMBING
PLOT PLAN (Indicate Building setbacks, abutting streets) HEAT & GAS LINE
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DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
I hereby acknowledge that I have read this application; that the In- TOTAL AMOUNT DUE
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 APPLICATION APPROVAL
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 TIUS PERMIT This application Is not a permit until
relating to Workmen's Compensation Insurance. AUTHORIZES signed by the Building Official or his Dep-
NOTE: Permit Limit One Year (Except DEMOLITIONS which ONLY THE uty; and fees are paid, and receipt is ac-
shall be completed In ninety days: MOVED -IN BUILDINGS shall be com- WORK 140TED lmowledged in space provided.
pleted In six months.) 4
-9-16MATURE (OWNE AGENT) DATE SIGNED INSPECTION DIRECT7K0,,,__
L& DEPARTMENT
7-� 170 CITY OF DATE I
V NOTE: Applicant Subject to Plats Chech Fee EDIVIONDS -.70
PR 0-1107
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways, F7LE
rmurque,es, etc.) will require separate permission.
Parking
Landscaping
Fire Dept.
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