M-106-66.pdfIMPORT,(INT! Press Firmly While Writing Application!
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B671ilW1iCg R�-ii®ciltm®91 Permit
PERMIT 'A ,( /
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NUMBER l�/1 (0
OWNER'S NAME
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NEW SITE ADDRESS
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MAILING ADDRESS
EDMONDS PRE -MOVE
INSPECTION
PERMIT NO.
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CITY & 'LONE TEL. NO.
1 2 3
'LONE I
ZONE
FOR WOBLDG R RMIT NO.
AT NEW SITE
33 G��•' •7 _ �� /�I
WET I/� L /
MOVING TRACTOR
MOVE CONTRAC OR'S INSURANCE COVERAGE
STREET ADDR EBB
NAME OF SURETY Y
PROVIDING P.L. &
P.D. COVERAGE i
CITY &ZONE
TE//L��NO.
STREET ADDRESS
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CONTRACTOR'S
STATE '�7 � —>
CITY BUSINESS
CITY, ZONE &STATE
LICENSE NO, _Z2 � o%.i el
7_1:�CENSE NO.
VALID S CE, POLICY CHECKED BY:
DATE
SITE DESCRIPTION
I
ADDRESS OF PRESENT BUILDIN SITE
BUILDING DESCRIPTION
l.cgnl )rscripticm of P,e,,nt Bil._ Site — (9 a• 1 w or atttach four copies)
DESC7E BASIC CONSTRUCTION % PRESENT USE OF BUILDING:
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OV LLL LENGTH OF BUILDING: p 7r.
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ADDRESS OF NEWp BUIZL/J�ING E
HEIGHT AS LOADED WIDTH AS LOADED BLDG. AREA
20 I /i"e
CZ�--
FT. FT. 84. PT.
POLICE DEPT. APPROVAL OF MO ING ROUTE DATE
f.egnl Deseriptio 1
'1N'ew Bldg, Site— (Show pelow or attach four_ co fes)
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Time to Commence Moving:
rrt�.a:•ss :� /�,9
Time to Finish Moving: ................u.. .l:�......... .:(..:.►.c.......
MOVING R T
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FIRE DEPARTMENT CLEARANCE OF ROUTING
DA,
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ENGIN1RING CLEA ANCE !
DATE
CLEARED BY:
Power Company ❑............!%.r1...G�''ft4�.:.1....�.�..:^.C.:..Y•'.�
RELOCATION RECEIPT NO.
PERMIT ��—V� / +�
Telephone Company ❑................................................................................
FEE S ('% .. fJ C� �� 5��•
NA OF ER OFF PRESENT BUILDI SITE
ATTENTION:
PERMIT APPROVAL
.I-L %i dam:--J C_ ,. f_
THIS PERMIT
THIS PERMIT DOES NOT BECOME
MAIL OR HOME ADDRESS '
AUTHORIZES
VALID UNTIL SIGNED BY THE
ONLY THE
RELOCATION
BUILDING OFFICIAL OR HIS DEPU-
TY, THE FEES ARE PAID, AND RE-
CEIPT IS ACKNOWLEDGED IN THE
I hereby acknowledge that I have read this application; that
the information given is correct; and that I am the owner, a
OF THE
SPACE PROVIDED
duly licensed moving contractor, or the authorized agent of one
BUILDING
of these. I agree to comply with city and state laws regulating
building relocation; and in doing this work, no person will be
employed in violation of the Labor Code, State of Washington
NOTED
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By i
relating to Workmen's Compensation Insurance.
..................................... . .........
Director's signstur
Signature of Owner,
Contractor, or
BUILDING
INSPECTION
.. ........ ...................
...
Authorized Agent ..... , .e /1....-_...._„.,_ Z.
DE PART31UNT
Date -' � Ys .................. ...................
g - _
Address //,�'�/S `::."...., `�:_...._ Nonel�-'.'.[.2....e
"' '
CITY OF
EDMONDS
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DISTRIBUTION OF COPIES
City .. .. " .......... .......................................................................
PR c-1Io:
WHITE — File (Bldg. Dept.)
Date ::........lf...l....
YELLOW — Move Inspector
GREEN — Assessor
.............. -rf.�t.......--........................ .......................................
GOLDENROD — Police Dept.
j�
K — Moving Contractor
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