760480.pdfBUILDING DEPARTMENT
PERMIT APPLICATION
NAME (OR NAME OF BUSINESS)
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❑ NEW
ADD
ALTER
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NUMBER OF S'
Si
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Applicant Fill � S
Inside Heavy Lines JOB
ADDRESS
L GAL LOT
`f YES ❑ NO
�R%v COND, USE NO,
'HONE NUMBER-�I
1� ZZI PROP�OfSED YARDS
V FRONT S O N
ANCE OR
ALLOWABLE
SIGN AREA
OTHER //////������
REQUIREMENT��
PERMIT
NUMBER
LOT AR SUBDIVISION NO,
ADS NO.
4r 'A`y' HEIGHT Z
.� E /� REAR r�' Z
PROPOSED .<1
SIGN AREA a
ELEPHONE NUMBER t�
(PLANNING DEPT. APPROVAL
STREET R/W
:::
EXISTING STREET R/W
COMP, PLAN ST, R/W
NUMBER REMARKS
a p 4- ° to
DATE
FT, DEFICIENCY THIS PROPERTY
FT, FT.
or Attach Four Copies) STREET AND/OR UTILITY
WORK REQ'D ❑ NO
UNDERGROUND ❑ YES
WIRING REQ'D ❑ NO
w TYPE CONNECTION
SEPTIC SYSTEM
APPVD BY CITY ENG,
M
RESIDENTIAL ❑GAS
LINE FIRE ZO
ro NON-RESIDENTIAL ❑SIGN
❑ DEMOLISH ❑ RETAINING SPECIAL If%
WALL REQUIRED
❑EXCAVATE FENCE ..-_ ❑ YES
OR FILL ❑ I. X FT) PLAN CHE(
DPRE -MOVE SWIM
INSP, D POOL
IES NUMBER OF REMARKS
DWELLING
UNITS
' WORK TO BE DONE /
c
ABUTTING
l
1 hereby acknowledge that I have read this application; that the in.
formation given la correct; and that I am the owner, or the duly author.
tztd agent of the owner. I agree to comply with city and state laws regu.
tathrg construction; and In doing the work authorized thereby, no person
will be employed In violation of the Labor Code of the Stale of Washington
re2atmg to Workmen's Compensation Insurance,
NOTE: Permit Limit One Year (Except DEMOLITIONS which
aw•tt be completed In ninety days; MOVED -IN BUILDINGS shall be com.
PItteb-I#t piz months.)
SI ATIgi E (OWN O I AE',ENT) DATE SIG ED
YL>f f L V�k fL-) CZ �` �U
NOTE: Applicant Subject to Plan Check Fee
0 This Permit covers work to be done on private property ONLY.
Any construction on the public domain (curbs, sidewalks, driveways,
marquees, etc.) will require separate permission.
PLAN CHECK
NO*
BUILDING
CHECKED BY
❑ YES
RIFT
U YES
❑ NO
SLEA RAI
ev STW
TYPE OF CONSTRUCTION CODE
y
^IV 1
PLUMBING
HEAT & GAS LINE
FENCE
SIGN
RETAINING WALL
SWIMMING POOL
TOTAL AMOUNT DUE
ATTENTION
THIS PERMIT
AUTHORIZES
ONLY THE
WORK NOTED
INSPECTION
DEPARTMENT
CITY OF
EDMONDS
775-2525
GROUP _Wr� ILOAD
OF EDMONDS. LOCAL SALES TAX
VALUATION
s V,
FEE
N !z
60
qr 06 10 /t<01
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.
RECTOR,!AIGNAIr LY14. 1
DATE
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