710521.pdf�POSTED ON KROLL MAP NO.; I PERMIT.R I I Uv�L!
BUILDING DEPARTMENT Applicant FIU NUMB-
Inside Heavy Lines JOB ADDRESS
PERMIT APPLICATION
NAME (OR NAME OF BUSINESS) Q lZe %
e / >W- SIDE YARD SETBACK I STREET SETBACK I REAR YARD SETBACH
MAILING ADDRESS /C zD
/3 E�� �� USE ZONE LOT AREA VACANT BITE
O CITY L' TELEPHONE NUMBER I I 0 YES � NO
�,�% /)%!J /1/�✓ W/7s'N , % %JP 7e J 1 HEIGHT I BUILDING AREA I VARIANCE NUASBER
NAME
PLOT PLAN APPROVED {
ADDRESS
F STREET BIW °•
TELEPHONE N
EXISTING STREET R/W ............FT. DEFICIENCY THIS PROPERTY
CITY UMBER
COMP. PLAN ST. R/W ............FT. ............FT. 0
REMARKS
j' NAME
03 U ADDRESS x
W
c CHECKED BY
t0 CITY I TELEPHONE NUMBER
z
METER SIZE SERVICE SIZE CLEARANCE CHECKED BY
STATE LICENSE NUMBER CITY LICENSE NUMBER
REMARKS 11tt
Legal Description of Property (8how ]Below or Attach Four Copies)
TYPE CONNECTION (VERIFIED BY .j
O Ij!
F PERC. TEST I PERMIT NUMBER
REMARKS m .`
G
0 FIRE ZONE I TYPE OF CONSTRUCTION STREET IMPROVED
.7 I 0 YES ❑ NO'�`•i
SPECIAL INSPECTOR REQUIRED (OCCUPANCY GROUP
® RESIDENTIAL n GAS ❑ YES i] 1
El NEW ll JJ LINE PLAN CHECKED BY SITE IS L
^
ElNON-RESIDENTIAL ElSIGN CITY OF L
i
ADD RATAININ6 REMARKS
DEMOLISH 0 WAIT' TA�CSHOULD BE CODE
ALTER EXCAVATE FENCE
❑ OR FILL (.......... x.......... Ft.)
El REPAIR PRE -MOVE SWIM
INSP. El POOL
NUASBER OF STORIES NUMBER OF
DWELLING
UNITS /
NATURE OF WORK TO BE DONE Valuation Fee — Receipt No.
Plan Check No .....................
yFF BUILDING
PROPOSED USE
c� PLUMBING
PLOT PLAN (Indicate Building setbacks, abutting streets) HEAT & GAS LINE .'...`
3i
FENCE
SIGN
RETAINING WALL
SWIMMING POOL i
i
1
DEMOLITION
— i
PRE -MOVE INSPECTION o fl _
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 state laws regu- ATTENTION
]atlnB construction; and In doing the work authorized thereby, no Dereon
will be employed in violation of the Labor Code of the Stale of Washington THIS PERMIT
relating to Workmen's Compensation Insurance. AUTHORIZES
NOTE: ONLY TILE
NOTE: Permit Limit One Year (Except DEMOLITIONS which WORK NOTED
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
SIGNATURE (OWNER OR AGENT) DATE SIGNED INSPECTION
DEPARTMENT
%) Lt,L . Cif. G� rwi/�'�'Y"'� /v b CITY OF
EDMONDS
NOTE: Applicant Subject to Plan Check Fee PR 6-II07
Tbts Permit covers work to be done on private property UNLx.
Any construction on the public domaln (curbs, sidewalks, driveways,
marquees, etc.) will require separate Permission-
1 A S °-= I (673o 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.
t
0
b
r
I, Edith Prigger being duly sworn on oath,
depose and say:
i 1
^ That the papers and documents appearing on this roll of
' film, consisting of the following: i
Building Permits - 1953-1974
175th Street SW - 242nd Street SW
were photographed by your affiant and that said papers and !
documents are true and correct copies of the originals thereof
d f the Cit of Edmonds.
as the same appeared on record in custo y o y
That the microfilming of the papers and documents as aforesaid -
was done in the pursuance of, and in conformance with provisions
of the statutes in these cases made and provided for as they
appear in Title 40, of the Revised Code of Washington. k.
Signed
r ,
Subscribed and sworn to before me this �Q day of
197F
Notary P is in and for the tate
of Washington, residing at C�
h Wasington.
. y
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