710580.pdfPOSTED ON KROLL MAP NO.: PERMIT
BUILDING DEPARTMENT
Applicant Fill
NUMBER
-, -
PERMIT APPLICATION
Inside Heavy Lines
JOB ADDRESS p
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NAME (OR NAME OF BUSINESS)
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VAN
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BIDE YARD SETBACKI STREET SETBACK I
REAR YARD SETBACK
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MAILING ADDRESS
USE ZONE LOT AREA
VACANT BITE
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CITY
TTTTELEPHONE NUMBER
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❑ YES ❑ NO
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to
HEIGHT BUILDING AREA (
VARIANCE NUMBER
NAME
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PLOT PLAN APPROVED
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ADDRESS
1
F
STREET H/W
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EXISTING STREET R/W FT. THIS PROPERTY
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CITY
TELEPHONE NUMBER
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COUP.DEFICIENCY
PLAN ST. R/W ............FT.
............FT.
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REMARKS
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NAME
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ADDRESS
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CHECKED BY
CITY
TELEPHONE NUMBER
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STATE LICENSE NUMBER
CITY LICENSE NUMBER
METER SIZE I SERVICE SIZE CLEARANCE
CHECKED BY
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REMARKS
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1 Legal Descrlutlon of ProDertY whow Below or Attach Four Copies)
2I
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NEW
❑ ADD
ALTER
REPAIR
El RESIDENTIAL '�
OAS
LINE
NON-RESIDENTIAL
❑
SIGN
❑RETAINING
DEMOLISH
El
WALL
FENCE
❑EXCAVATE
OR FILL
(.......... x.......... Ft.)
®PRE
-MOVE
INSP.
❑
SWIM
POOL
DWELLING
UNITS
I hereby acknowledge that I have read thin 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 lawn 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 DE➢fOLITIONS which
shall be completed In ninety days; MOVED -IN BUILDINGS shall be com-
pleted In six months.)
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.) wW require separate permission.
❑ YES ❑ NO
❑ YES ❑ NO
THIS SITE IS LOCATED IN THE
TAX SHOULD COL:=D 31.04.
6�uTGqLs- T6 M6V GV A SO
Plau Check No.
BUILDING
PLUMBING
HEAT A OAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
DEMOLITION
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AIAOUNT DUE
Fee
e oD
;ov
No.
ATTENTION APPLICATION APPROVAL
THIS 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 DIREC 'e 8f U)
DEPARTMENT
CITY OF 1
EDMONDS DATE
PR 6-1167
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