710067.pdfr-
1 BUILDINGDI:'PARTMENT
PERMIT APPLICATI®N
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NAMEv I F O L 14 MST. A
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ADDRESS
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Applicant Fill
Inside Heavy Lines
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or
RESIDENTIAL
❑
GAB
LINE
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NON-RESIDENTIAL
❑
El ADD
SIGN
RETAIKING
❑
DEMOLISH
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WALL
EXAVATFE
E
ALTER
El
ORCFILL
El
(.ENOx
Ft.)
REPAIR
❑
PRE -swim
❑
..........
INSP.
POOL
iUMBER OF STORIES
NUMBER OF
DWELLING
I
UNITS
DN KROLL MAP NO.: PERMIT 100(
NUMBER U
tEae
i] YES 17 NO
EXISTING STREET R/W ............FT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W ............FT. ............FT.
REMARKS
TYPE
YES [] NO
N A / Y., � [s
r
Plan Check No .....................
BUILDING
PLUMBING
[backs, abutting streets)
HEAT k GAS LINE
FENCE
SIGN
1
RETAINING WALL
N
I
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
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 DEMOLITIONS which
ONLY
NOT D
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
p t d In six months.)
11
(OWNR
DATE SIGN 'D
INSPECTION
ONTURE
:RYAE-N
L/ r�
DEPARTMENT
CITY OF
EDhLONDB
NOTE: Applicant Subject Plan Check Fee
PR 8-3107
This Permit covets work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marquees, etc.) will require separate permission.
3
[] YES 13 NO
o V
Fee
Sa
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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.
DATE 1
FILE
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