640228.pdf---------- --------
.AN FILE NUMBER BUILDING
Applicant Fill PERMIT
Building Permit Application lInside Heavy Lines NUMBER 640228
XAM� (OR N7 JOB ADDRESS
Ue (71IUSIN513y'
ZZ
MAILING AIHJnBH8 SIDE YARD SET BACK REAH, YARD
CITY TELEPRONZ-NUMBII;R USE ZONE MAP NUMBER VACANT SITE
/ 0 YES [3 No
/43 V
N"E BUILDING AREA LOT AREA VARIANCE NUMBER
Z
ADDRESS HEIGHT L BUILDING SETBACKS N
TELEPHONE NUMBER REMARKS NOTE: 'T EAVE LINES
C�
ADDRESET Encroachment Permit FERMIT NUMBER STREET GRADE CHECK
Required Z
Cl YES NO
CITY f TELEPHONE NUMB METER SIZE SERVICE SIZE CLEARANCE CHECKED BY
S2?FTE LICENSE NUMBER CITY LICENSE NUM REMA
LA.
LOT BLOCK TRACT
- - - - - - - - - - -
TYPE CONNECTION FIED
PERC.TESV UMBER 00
FIRE ZONE TY STRUCTION STREET IMPROVED
*7_Xe-
6 Zee-'?O* -4�ellv YES [j No
Z REQUIRED
SPECIAL INSPECTOR OCCUPANCY GROUP
0 YES NO
PLAN CHECKED BY
WORK TO 13E DONE
TOTAL PIER Z
NO. OF EILDG$. PERIBLOG.
1-d 1004 BUILDING
,C=
VALUATION
BUILDING PERMIT so
NUMBER OF STORIE 2 FEE
0--��w 0 DEMOLISH PLUMBING
ADD 3 PERMIT FEE
HEAT & GAS LINE
NUMBER OF 4 PERMIT FEE
Fj ALTER RESIDENTIAL
V- Ell& <
DWELLING
FREPAIR NO] UNITS DEMOLJTION
1 1:1 1 5 PERMIT FEE
P-R—OPOSED USE
6 AMOUNT DUE
I hereby acknowledge that I have read this application: that th In-
e or- APPLICATION APPROVAL
formation given Is correct; Bad that I am the owner, or the duly auth ATTENTION
ized agent of the owner. I agree to comply with city and state laws regu.
TIUS PERMIT This application is not a permit until
lating construction; and In doing the work authorized thereby, no person AUTHORIZES signed by the Director of Building Inspec-
of the Labor Code of the State of Washington
will be employed In violation ONLY TILE
relating to Workmen's Compensation Insurance. WORK NOTED tion, or his deputy; and fees are paid, and
receipt is acknowledged In space provided.
R
NOTE"PERMIT LIMIT 01`10 YEA
yj rm
DATE SIGNE IGNATURE
SIG.N ?Pff-�(-OWNWR 0, ENT) D INSPECTION DIRECTO
DEPARTMENT
CITY OF
DArE
EDMONDS
PLOT F�AN OH� APPROVED
PR 0-1107
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7 33.11LE
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