740524.pdfBUILDING DEPARTMENT I Appllcal
PERMIT APPLICATION Inside Hen
N E (OR NAME OF BUSINESS)
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CITYTELEPHONE NO
Fr, NAME
IU,1 ADDRESS
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CITY TELEPHONE NU
NAME
104 G ADDRESS
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F CITY I TELEPHONE NI,
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STATE LICENSE NUMBER CITY LICENSE
Legal eecrlptlon et Property (Show Below or Attach Four 0
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.- •. -
RESIDENTIAL
LEGAL LOT
GAS
NEW
L--1
INE
ADD
NON-RESIDENTIAL
❑
SIGN
EXISTING STREET R/W ............FT. DEFICIENCY THIS PROPERTY
® DEMOLISH
COMP. PLAN ST. R/W ............FT. ............FT.
RETAINING
WALL
ALTER
EXAVA❑ TE
O
OROFILL
E]FENC.
.......... Pt.)
REPAIR
❑ INSP.
O
POOL
Fuh- BER OF STORIES NUhIBER OF
DWELLING
REMARHtl
e
/1 UNITS /I
I
,
.- •. -
Plan Check No .....................
LEGAL LOT
VARIANCE OR CONDITIONAL USE
0 YES 0 NO
PERMIT NUMBER
.- •. -
Plan Check No .....................
PLANNING DEPT. APPROVAL DATE:
STREET R/W
EXISTING STREET R/W ............FT. DEFICIENCY THIS PROPERTY
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COMP. PLAN ST. R/W ............FT. ............FT.
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REMARKS
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I CHECKED BY
o,__1 tl1LE SERVICE SIZE CLEARANCE
CHECKED BY
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PLUMBING
ICd
REMARHtl
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I
TYPE CONNECTION I VERIFIED BY
PLRC. TEST PERMIT NUMBER
1d
I
REMARKS
N/a
m
FITYPE OF CONSTRUCTION STREET IMPROVED
ir
I [3 YES [] NO
SPECIAL INSPECTOR REQUIRED GROUP
IOCCUPANCY
❑ YES 0 NO
FLAN CHECKED BY THIS SITE IS LOCATED IN THE CITY
-
OFEDMONDS. LOCAL SALES TAX
HOULD BE CODED 31.04.
REMARKS
_
RETAINING WALL
1
Valuation
Fee
Receipt No.
.- •. -
Plan Check No .....................
HUILDINC
PROPOSED UBE /
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PLUMBING
PLOT PLAN (Indicate Building setbacks, abutting Metals)
BEAT &CAB LINE
21
FENCE
-
SIGN
_
RETAINING WALL
eW1MMIN6 POOL
DEMOLITION
L Q
PRE -MOVE INSPECTION
EXCAVATION OR FILL
,
('U
TOTAL AMOUNT DILE
I hereby acknowledge that I have read this application; that the In*
formalElven le correct; and that I am the owner, or the duly author-
agent owner. I agree to comply with oily and stale Inws ergo•
latiIzed
tr cto
toting construction; and In doing the work authorized Ularaby, no Dersun
ATTENTION
APPLICATION APPROVAL
will be employed In vlolnllon D1 the Labor Code of the State of Washington
THIS PERMIT
This application Is not a permit until
relntlag to Workmen's Compensation Insurance.
AUTHORIZES
ONLY THE
Signed by the Building Official or his Dep-
NOTE: Permit Limit One Year (Except DEMOLITIONS whichWOnK
NOTED
uty; and fees are paid, and receipt is ac -
shall be completed In ninety days; MOVED -IN BUILDINGS shall be cone.
knowledged in ace provided.
p p
plated in six months.)
SIGNATURE (OWNER OR AGENT) DATE SIGNED
INSPECTION
DIRECTO ' B10 Tl RE
I
DEPARTMENT4�
4,�.
CITY OF
NOTE: Applicant Subject to Plan Check Fee
EDIVIONDS
DATE
q•--�-- 7 (� -
This Permit coven work to be don n private property ONLY.
775.2528
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