710270.pdfBUILDING DEPARTMENT
PERMIT APPLICATION
rA
NA E ( B(+#
Applicant Fill
Inside Heavy Lines
'1
2617- 746
i
TELEPHONE NUMBLI
ADDREBB
76
PELEPHONE NUMBS
ai
ADDRESS
`--G'rJr�;
-t I7' 7Ll i
CITY
r
TELEPHONE NUMBE
STATE LICENSE NUMBER
CITY LICENSE NUM
I
Legal Description of Property (Show Below or Attach Four Copley
7
a
to
r
NEW
❑ ADD
❑ ALTER
REPAIR
7UMBER OF S
RESIDENTIAL
❑
GA8
LINE
NON-RESIDENTIAL
❑
SIGN
❑RETAINING
DEMOLISH
El
WALL
❑EXCAVATE
FENCE
OR FILL
(.......... x.......... Ft.)
PRE -MOVE
El
SWIM
INSP.
POOL
.lEa
NUMBER OF
DWELLING
/
UNITS
K TO BE DONE
r
I
ROLL MAP NO.: PERMIT
Q NUMBER
ETBACK I STREET BETTI13ACK
t
s
71021
/C 1 / / /.fn✓ ♦
r7
;
c7
�+
r
i
.CANT BITE
YES NO
'T
N
f
I
t
,RIANCE NUMBER
EXISTING STREET R/W M... FT. DEFICIENCrYY THIS PROPERTY
COMP. PLAN ST. R/W 60•FT. ..C-.)•.... FT.
REMARKS
Driv®ray slopes not to exceed those indicated
on Standard Drawing #103_._
Q
TYPE OF
I\/ D YES NO
SPA;e CL INSPECTOR REQUIRED OCCUPANCL GROIJP T
❑ YES NO
—
Plan Check No .....................
BUILDING
PLUMBING
HEAT A GAS LINE
FENCE
SIGN
TRETAINING
WALL
N
ISWIMMING
POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
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-
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
shall be completed 1n ninety days; MOVED -IN BUILDINGS shall be com.
pleted In six months.)
ItGNATURF (OWNER, Ott AGENT) :�A
T ' SIG ll
�;
NOTE: Applicant Subject to Plan Check Fee
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marquees, etc.) will require separate permission.
Valuation I Fee
ro
1 I VJ0.
No.
TOTAL AMOUNT DUE
I
I /_S!♦ V `�
ATTENTION
APPLICATIOIICCNJJN APPROVAL
THIS PERMIT
This application is not a permit until
AUTHORIZES
signed by the Building Official or his Dep-
ONLY THE
uty; and fees are paid, and receipt is ac-
NOTED
R'ORK NOTED
llnowledged in space provided.
INSPECTION
DIRECTO a GNAT E
DEPARTMENT
CITY OF
DATE-
-7
/ /
EDMONDS
_ PR 6-1107
FILE
f
I
i
JJ
I