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BUILDING DEPARTMENT
PERMIT APPLICATION
C, ;
Applicant Fill
Inside Heavy Lines
/ ` /ON do •UMH 'R TMLEPH
NAME
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ADDRE88
D,( (S ti w C3 C3
C1TY TELEPHONE NUMBER
tom_ Q..� 1 2. V
c0
a�-
q
4pkrqEw
ADD
ALTER
REPAIR
di
RESIDENTIAL
DEMOLISH
EXCAVATE
OR FILL
PRE -MOVE
INSP,
IES NUMBER O
DWELLING
UNITS
�_ d
OAS
WL
LINE
ElSIGN
RETAINING
WALL
OFENCE
(... _... i........ Ft. )
rl
SWIM
11
MOM
(w is I
NO,: I PERMIT
NUMBER l.1 '.J I I I l J2
+
Alit) SETBACK '{
O
BITE
NO
CE NUMBER
y
,
EXISTING STREET R/W ............FT. DEFICIENCY THIS PROPERTY I t
COMP, PLAN ST, R/W ............FT. ............FT. t7 -
REMARKS
El YES ❑ NO
■ ■
THIS SITE IS LOCATED IN THc
REMARKSLOCAL SALES
TAX SHOULD BE CODED 31.04.
Plan Check No...._.._.._.......
i11iffffi-D]=
PLUMBING
is �F+I-LLL•'
FENCE
SIGN
RETAINING WALL
1�t4T�•1�I�11 S•Z•3�
DEMOLITION
EXCAVATION OR FILL
TOTAL AMOUNT DUE
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 date laws regu. ATTENTION
lating construction; and in doing the work authorized thereby, no person
will be employed In violation of the Labor Cade of the State of Washington THIS PERMIT
relating to Workmen's Compensation Insurance, AUTHORIZES
Y THE
E: Permit imit One Year (Except DEMOLITIONS which W K NOTED
shall a comarta nett' days; MOVED -IN BUILDINGS shall be com-
�lele la six m the,
SION TURF NE OR AGENT) DATE GNED INSPECTION
DEPARTMENT
F/ CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee
PR a-Iloy
This Permit coven work to be done on private property ONLY•
Any construction on the pnbUo domain (earbe, sidewalks, driveways,
marquees, etc.) Nls require Separate permission.
Valuation
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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