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a Applicant FillBuilding Permit Application Inside Heavy Lines
'r f1.:. NAME (OR NAME OF BUSINESS) JOB ADDRESS
�C' BIDE YARD
LINO ADDRESS
}) CITYTELEPHONE NUMBER USE ONE
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21-
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PERMIT- 640223
NUMBER
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SET BACK I REAR YARD
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MAPNUSSMBER VACANT SITE,(
/ 0 d I ❑ YES !(NO
} Required
n YES NO
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(TELEPHONE NUMBER
METh%ii SIZE I SERVICE
CENSE NUMBER CITY LICENSE NUMBER REMARKS
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<' TYPE CONNECTION
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FIRE ZONE TYPE Ol
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C SPECIAL INSPECTOR X
n. YES ❑ NO
PLAN CHDC D BY
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� WORK TO BE DONE
�izG�-� T ro�CA C L BUILDING
1 VALUATION
BUILDING PERMIT
NUMBER S FEE OF STORSEB
NEW � DEMOLISH I I PLUMBING
3 PERMIT FEE
ADD HEAT A GAS LINE
NUMBER OF 4 PERMIT FEE
�^ ALTER RESIDENTIAL DWELLING
I REPAIR I NON-RESIDENTIAL UNITS 5 PERM TTION FEE
g AMOUNT DUE
I hereby acknowledge that I have read this application; that the In- ATTENTION
formation given 10 correct; and that I am the owner, or the duly author- THIS PERMIT
lzed agent of the owner. I agree to comply with city and state laws iegu- HIS PR MI
]sting construction; and In doing the work authorized thereby, no person ONLY THE
ZES
will be employed 1n violation of the Labor Code of the State of Washington
relating to Workmen's Compensation Insurance. WORK NOTED
NOTE: PERMIT LIMIT ONE YEAR INSPECTION
3IGNATU (OWNER AGENT) DATE SIGNED
DEPARTMENT
CITY OF
ETDMONDS
I.OT,pt;,'q CHEC A -APPROVED
TT / PR 6-1107
FILE
ALL BUILDING SETBACKS
NOTE: TO EAVE LINES
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APPLICATION APPROVAL
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This application is not a permit until
signed by the Director of Building Inspec-
tion, or his deputy; and fees are paid, and
receipt is acknowledged in space provided.
//x/G
Official
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