710157.pdfF
Applicant Fill
Inside Heavy Lines
MAILING ADDRE
4
NAME
AUDRESS
CITY
IMF
EXISTING STREET R/W
COMP. PLAN ST. R/W ............FT.
NAME
94
ADDRESS
CITY
TELEPHONE NUMBER
STATE LICENSE NUMBER
CITY LICENSE NUMBER
223 4
Legal Description or Property (Show Below or Attach Four Copies)
Z
/vck
to
GAS
RESIDENTIAL O LINE
NON-RESIDENTIAL SIGN
ElADD RETAINING
DEMOLISH W.4.LL
ALTER EXCAVATE FENCE
OR FILL ........ x . ........ Ft.)
REPAIR PRE -MOVE SWIM
El INSP. El POOL
NUMBER OF STORIES
NUMBER OF
DWELLING
UNITS
NATURE OF WORK WORK TO BE DONE
PROPOSED USE
12
PLOT PLAN (Indicate Building setbacks, abutting streets)
21
0
ft
t
N
I
I hereby Rcknowledso that I have read this application; that the In.
formation given In correct; and that I am the owner, or the duly author-
ised agent of the owner. I agree to comply with city and state laws regu-
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
relating to Workmen's Compensation Insurance.
NOTE: Permit Limit One Year (Except DEMOLITIONS which
I
4hLII be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
SIGNATURE (OWNER Olt AGENT)
8
DATE STONED
NOTE: Applicant Subject to Plan Check Fee
This Permit covers work to be done on private propedy ONLY.
Any construction on the public domain (curbs, eldewalkso drivewayst
marquees, etc.) will require separate permission.
:1 YES 0 NO
PLAN CHECKED BY
REMARKS
7
PERMIT
I U I b I
NUMBER
ACK
REAR YARD SETBACK
I
VACANT SITE
C] YES E3 NO
.EA
VARIANCE NUMBER
I
DEFICIENCY THIS PROPERTY
U
Plan Check No............_.......
Valuation
Fee
BUILDING
PLUMBING
HEAT & GAR LINE
PENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
N I
0 0
ATTENTION APPLICATION APPROVAL
THIS PERMIT This application Is not a permit until
AUTTHE THOHE ZES Signed by the Building Official or his Dep-
ON
WORK NOTED uty; and fees are paid, and receipt is ac-
Imowledged in space provided.
INSPECTION D R R-S 8101t ATU74
DEPARTMENT �1_17
CITY OF Qua
EDMONDS DATE
PR 6-1107
FILE
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