710421.pdfBUILDING DEPARTMENT ApplloantFM
PERMIT APPLICATION Inside Heavy Lines
7ULLlYlVY Ay/L[wun � � '
Z
,
• i; NAME
at
of
Z
/ U
Bs
CITY
F
8
STATE LICENBffi NtJMHE
Legal Nicrlptlon of Prope
NEW
ADD
ALTER
REPAIR
e
or
0
RESIDENTIAL
OAS
LINE
NON-RESIDENTIAL
❑
SIGN
DEMOLISH
❑
RETAINING
EXCAVATE
OR FILL
El
FENCE
(........ ..x.......... Ft.)
I `
PRE -MOVE
INSP.
SWIM
POOL
DWELLING
UNITS
KROLL MAP No.:
3 r]
EXISTING STREET R/W ............FT.
COMP. PLAN ST. R/W ............FT-
YES
NO
Plan Check No .....................
BUILDING
PLUMBING
BEAT do GAS LINE
FENCE
SIGN
RETAINING 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 thatiam tLe owner, or the duly author-
Ized agent of the owner. I agree to comply with city and state laws regu-
ATTENTION
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
THIS PERMIT
relating to Workmen's Compensation Insurance.
AUTHORIZES
ONLY THE
Permit tamit One Year (Except DEMOLITIONS which
WORK NOTED
shall a compleI n nl ety days; MOVED -IN BUILDINGS shall be tem-
plet In six nths.)
INSPECTION
BIG ATURE WNE OR AGENT) DATE S%IGNED
DEPARTMENT
Z
/
CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
10
PR 6-1107
This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, drlvewgs,
marquees, etc.) will require separate permission.
PERMIT
NUMBER
avc �
710421
l7 YEB
❑ NO
DEFICIENCY THIS PROPERTY
❑ YES ❑ NO
THIS SITE IS LOCATED IN
TAX SHOULD BE CODED 3
Valuation
,
kill,
No. I
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.
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