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UILDING DEPARTMENT I Applicant Fill
PERMIT APPLICATION Inside Heavy Lines
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GAS
RESIDENTIAL LINE
NEW ❑ NON-RESIDENTIAL ❑ SIGN
ADD RETAINING
DEMOLISH WAIT'
ALTER EXCAVATE ❑ FENCE
OR FILL (.......... x..........
Ft.)
REPAIR PRE -MOVE SWIM
INSP. POOL
iUMBER OF STORIES I NUMBER OF
DWELLING r
UNITS
QATURE OF WORK TO BE DONE
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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 slate 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 In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
IIGNATURE (OWNER OR A
/ /GEWy') DATE SIGNED
)
v A I / /
NOTE: A,Wicant SubjecVlto Plan Check Fee
This Permit coCers work to be done on private property ONLY.
Any construction on the public domain (curbs, slderralks, driveways,
marquees, etc.) will require separate permission.
C
N KROLL MAP NO.: PERMIT
NUMBER A
pas act
7_y'-: N—
KISTING STREET R/W ............FT.
COMP. PLAN ST. R/W ............FT.
ZONE I TYPE OF
0 YES [] NO
YES
NUMBER
DEFICIENCY THIS PROPERTY
O YES )] NO
CITY OF EDMONDS. LOCAL SALE
REMARKS I AX SHOULD BE CODED 31.04.
,Q_l. 6r9,AD 1 W Gr TO H eEi
Valuation
Plan Check No....
BUILDING
PLUMBING
HEAT d: GAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
r
Fee
10.06
No.
TOTAL AMOUNT DUE
I
I 16.1171
16117
ATTENTION
APPLICATION APPROVAL
TMO PERMIT
This application is not a permit until
AUTHORIZES
signed by the Building Official or his Dep-
ONLY THE
WORK NOTED
uty; and fees are paid, and receipt is ac-
knowledged in space provided.
INSPECTION
DIRE '8 SIGN
DEPARTMENT
CITY OF
DPH
EDMONDS
6-1107
FILE
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