710123.pdfs�
DEPARTMENT
PPLICATION
�L�oo
:.a
Applicant Fill
Inside Heavy Lines
6 ark-%
TELEPHONE NUMBER
AJciS IP�'� �336-a
CENSE NUMBER CITY LICENSE NUMBER
�Y
miptlon of Property (Show Below or Attach Four Copies)
GAS
EW K—� RESIDENTIAL LINE
'%% �\\ LEI NON-RESIDENTIAL ❑ SIGN
ADD ElDEMOLISH ❑ RETAINING
LL
ALTER ❑ OROFIILTE ❑ PENCEx......... Ft.)
REPAIR SWIM
❑ INSP. a POOL
;UMBER OF STORIES NUMBER OF
DWELLING
UNITS
)N KROLL HAP NO.: PERMIT
NUMBER
LESS go q . / `
EXISTING STREET R/W ............FT.
COMP. PLAN ST. R/W ............FT.
❑ YES ❑ NO
i
Plan Check No .....................
A
BUILDING
PROPOSED USE
0
tt��y
PLUMBING
Q
si
PLOT PLAN (Indicate Building setbacks, abutting streets)
tRETAINING
N
1
HEAT do GAS LINE
FENCE
SIGN
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-
formation given Is correct; and that I am the owner, or the duly author-
tzed agent of the owner. I agree to comply with city and state laws regu-
ATTENTION
lattng 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
relating to Workmen's Compensation Insurance.
AUTHORIZES
NOTE: Permit Limit One Year (Except DEMOLITIONS which
ONLY THE
WORK NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
i1GNATU W R OR AGENT) DATE IGNE
INSPECTION
�J �/
DEPARTMENT
OITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
PR a-Ilov
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, drlvewsys,
marquees, etc.) will require separate permission.
710123
S.
❑ YES ❑ NO
DEFICIENCY THIS PROPERTY
❑ YES ❑ NO
Fee
No.
1 v90, &-01 sq/9
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-
lmowledged in space provided.
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:, RD::OFINSPECTIONS uler; a ,
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Date Passed
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