M-4-78.pdfV
IMPORTANT! Press Firmly While Writing Applicatims!
cant rlll
Building Relocation Permit Inside AppliHeavy Lines
Al NUMBER
OWNER'S NAME
NEW SITE ADDRESS
%1
SAILING ADDRESS
G
4EUMOND3
G�
I
PRE -MOVE
INSPECTION a
PERMIT NO.
CITY & ZONE TEL. NO.
r-// 11 -- e C! r�
�� ��
b'IRE
''LONE I 2 3
q
BLDG. PERMIT NO.
FOR WORK
/%%/�� / a
&�
AT NEW SITE
Ll
MOVING CONTRACTOR
`/�L-
MOVE CONTRACTOR'S INSURANCE COVERAGE
' 1 '% �/ [//LDS/ rL�i �i•t'i i7� /
NAME OF SURETY'
PROVIDING P.L. &
STREET ADDRESS
P.D. COVERAGE
CITY & ZONE
STREET ADDRESS
I ,, & STATE
CONTRACTOR'S
STATE )
CITY BUSINESS
�ZONf
/J� �/(^
Vr^-'
�1� '--"v tl r•^�V , Ie O I
LICENSE NO 5 O, lell
LICENSE NO.
VALID INSURANCE PCY CHECKED BY: DATE
O I
SITE DESCRIPTION
ADDRESS OF PRESENT BUILDING SITE
?/G, ,9.-/,.� 1, / 'ter
BUILDING DESCRIPTION!
Legal Description of Present Bldq. 81te — (Show below or attach four copies)
DESCRI �BA�SI_C CeON'STRUCTION & PRESENT USE OF BUILDING:
OVERALL LENGTH OF BUILDING: - o IT.
ADDRESS OF NEW BUILDING SITE
HEIGHT AS LOADED
WIDTH AS LOADED
BLDG. AREA
/
i?•cr /Z i �L �C' / / r.�G /%J
I`l.
J // FT .I
Legal Description of New Btdq. Site — ($how below or attach tour copies)
POLICE PT. OF MOVING ROUTE
DATE
S?'
WIPPROV
/ ('" W
Time to Commence Moving: ........... V...`.�........................
/jdG)�
Time to Finish Moving: .....................4P............................................
MOVING ROUTE
S �7 �f�/ ��,• f�/�
FIRE DEPARTMENT CLEARANCE OF ROUTING
/DATE
fQ
CLEARED BY:
RELOCATION
PowerCompany ❑........................................................................................
FEEI.IIT
TelephoneCompany p................................................................................
ATTENTION:
NAME OF OWNER OF PRESENT BUILDING SITE
THIS PERMIT
MAIL OR HOME ADDRESS
AUTHORIZES
ONLY THE
RELOCATION
I hereby acknowledge that I have read this application; that
the information given is correct; and that I am the owner, a
OF THE
duly licensed moving contractor, or the authorized agent of one
BUILDING
of these. I agree to comply with city and state laws regulating
NOTED
building relocation; and in doing this work, no person will be
employed in violation of the Labor Code, State of Washington
relating to Workmen's Compensation Insurance.
Signature of Owner, / ��/ /.'
Contractor, or / / /'
Authorized Agen/ :F-' /�.............. �..................
BUILDING
1xsPBCTlox
DEPARTMENT
Signer's ` Phone
`/ i�. No...: :�:�::-' ..��`..
CITY or
Address ! -•
EDMONDS
City ? lP •"'••"""......--• /...:....................................
PR s-1107
v 7
Date ..... ��:::!L�l.`......... -.:>.:.......�.::..f--•
t
F
G
I F
00 RECEIPT NO.
�-�
PERMIT APPROVAL
THIS PERMIT DOES NOT BECOME
VALID UNTIL SIGNED BY THE
BUILDING OFFICIAL OR HIS DEPU-
TY, THE FEES ARE PAID, AND RE-
CEIPT IS ACKNOWLEDGED IN THE
SPACE PROVIDED
By .:, i-A.... .....
DDiiirreclor'ss Signature
Date.................lt'.... !.................
DISTRIBUTION OF COPIES
WHITE — File (Bldg. Dept.)
YELLOW — Move Inspector
GREEN — Assessor
GOLDENROD — Police Dept.
PINK — Moving Contractor