710148.pdfBUILDING DEPARTMENT
PERMIT APPLICATION
NAME
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MAILING ADDRESS
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Applicant Flll
Inside Heavy Lines
fOB ADDRESS
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PERMIT
NUMBER
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❑ YES Cl NO
EXISTING STREET R/W ............FT. DEFICIENCY THIS PROPERTY
COMP. PLAN ST. R/W ............FT. ............FT.
REMARKS
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ADDRESS
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CHECKED BY
CITY
TELEPHONE NUMBER
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METER SIZE SERVICE SIZE CLEARANCE
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CHECKED BY
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STATE LICENSE NUMBER
CITY LIu4rist' NUMBER
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REMARKS
Legal Description of Property (Show Bclow or Attach Four Copies)
TYPE CONNECTION
VERIFIED BY
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PEI(C. TEST
PEREfIT NUMBER
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REMARKS
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OW
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FIRE ZONE TYPE OF CONSTRUCTION STREET IMPROVED
I ❑ YES ❑ NO
I
GAS ❑ YES ❑ NO
❑ NEW RESIDENTIAL ❑ LINE PLAN CHECKED BY
ElNON-RESIDENTIAL ❑ SIGN
❑ ADD ❑ DEMOLISH ❑ VE4LLINING REM 8
ElALTER EXAVAT❑ ORCFILL D El(ENCx.......... Ft.)
PRE -swim REPAIR ❑ IN P. O POOL
DWELLING
UNITS
Plan Check No...........
BUILDING
PLUMBING
HEAT do GAS LINE
FENCE
SIGN
RETAINING WALL
N
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SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
I hereby acknowledge that I have read this::h,lon; that the In-
formation given Is correct; and that I am the othe duly author-
ized agent of the owner. I agree to comply with elate laws regu-
ATTENTION
laling construction; and In doing the work authreby, no person
will ha employed In violation o[ the Labor Code oo of Washington
TLHB PERMIT
relating to Workmen's Compensation Insurance.
AUTHORIZES
NOTE: Permit Limit One Year (ExceLITIONS which
ONLY TILE
µ'ORK NOTED
shall be completed In ninety days; MOVED -IN BS shall be com-
pleted In six months.)
31 NATURE (OWNER OR AGENT) DATE SIGNED
INSPECTION
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DEPARTMENT
fIi`"-G1
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
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This Permit covers work to he done on private properly ONLY.
Any construction on the public domain (curbs, sidewalks, drlvew•g1s,
marquees, etc.) will require separate permission.
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Valuation I Fee
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s/ , 0 0 1�6 a S
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.
DIRECTOR'S VIGNATSJRL3
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DATE
FILE