710052.pdfr'
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BUILDING DEPARTMENT Applicant FIR
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PERMIT APPLICATION Inside Heavy Lines
NAME
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CITY LICENSE I
116`
(Show Below or Attach Four Ci
1,
)STSD ON KROLL MAP NO.: PERMIT
/ 'D I„1 NUMBER
JOB ADDR SS
�I93j—_ 1179
SIDE YARD SETBACK ISTREET
SETBACK I
REAR YARD SETBACK
USE ZONE
AREA
VACANT SITE
IK V v r�
ILOT
I p YES ❑ NO
HEIIII)G�`HTO00
I BUILDING AREA
I VARIANCE NUMBER
I`
PLOT PLAN APPROVEll
RESIDENTIAL
Q
OAS
LINE
NEW
NON-RESIDENTIAL
❑
SIGN
❑ ADD
RETAINING
❑
DEMOLISH
❑
,
❑ ALTER
❑
EXCAVATE
ORFILL
❑
tENC x
Ft.)
..........
REPAIR
❑
PRE -SWIM
INSP.
❑
POOL
(UMBER OF STORIES
NUMBER OF
DWELLING
I
UNITS
EXISTING STREET R/W ............FT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W ............FT. ............FT.
❑ YES 0 NO
STREET IMPROVED
❑ YES ❑ NO
Fee
t�
A4
CS
3
No.
Plan Check No .....................
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BUILDING
((yyy
y
FA
PROPOSED USE
PLUMBING
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0� L C� O
W
a
PLOT PLAN (Indicnle Building setbacks, abutting streets)
HEAT & 6A NE
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FENCE
SIGN
RETAINING WALL
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BWIMMIN6 POOL
DEMOLITION
PRE -MOVE INSPECTION
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EXCAVATION OR FILL
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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 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
NOTE: Permit Limit One Year (Except DE51OLITIONS which
ONLY TILE
WORK NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
NATURE (OWNER Olt AGENT) DATE SIGNED
INSPECTION
DEPARTMENT
CITY OF
EDIVIONDS
NOTE: Applicant Subject to Plan Check Fee
rn a-Ilo7
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sldewalks, driveways.
marquees, etc.) will require separate permission.
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.
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