750163.pdfi
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BUILDING DEPARTMENT I Applicant Fill °NE NUMBER 750163
PERMIT APPLICATION Inside Heavy LineH JOB
ADDRESS /t n .--r�' /l i! n/ a /
a' MAILING ADDRESS
I' /11J- Fn/l.l iJa. ao r o..o
TYPE CONNECTION v•VERIFIfED BY
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� PERC. TEST IPE IT NUMBER (C
n r
a REMARKS m
,'Ij b�ZONE YpE OF CONSTRUCTION I STREET IMPROVED I
[I YES E] NO
NAM' v
FRONT HIDE REAR FRONT BIDE REAR
CAS
LINE
❑ YES ❑ NO
J
BUILDING
Cry, D
THIS SITE IS LOCATED IN THE CITY
0
ADD S
F
LEGAL LOT VARIANCE Oft CONDITIONAL USE
C3 YES [3 NO PERMIT NUMBER
❑
I TT
U Z
� HOUSALES TAX LD BE CODED 31 04
PLANNING DEPT. APPROVAL DATE:
IC C TY
TELEPHONE NUMBER
954
V O T
STREET R/W
EXISTING STREET R/W ............FT. DEFICIENCY THIS PROPERTY
V
OREXCAVATE
NAME
tQ
1_f_/_
O
�7 DDRESS
COMP. PLAN ST. R/W ............FT. ............Fe,
x
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REMARKS
HECKED BY
C CSI\Tpy� "� //
U p�(�li t
TELEPHONE NUMBER
�6� /a 8�
METER BILE
[fnG
SERVICE HlLE
CLEARANCE CHECKED BY
STATE LICENSE NUMBER1111
22, 19z -2
LICENSE 1111111
TYPE CONNECTION v•VERIFIfED BY
0
� PERC. TEST IPE IT NUMBER (C
n r
a REMARKS m
,'Ij b�ZONE YpE OF CONSTRUCTION I STREET IMPROVED I
[I YES E] NO
RESIDENTIAL
NEw
❑
CAS
LINE
❑ YES ❑ NO
J
BUILDING
PLAN CHECKED BY
THIS SITE IS LOCATED IN THE CITY
0
®
ADD
ALTER
NON-RESIDENTIAL
DEMOLISH
❑
SIGN
RETAINING
WALL
FENC
� HOUSALES TAX LD BE CODED 31 04
PLUMBING
REMARKS
U
OREXCAVATE
117
x .......... P,
HEAT & GAS LINE
❑
REPAIR ❑
PTIOVF.
PRE-INSP.
❑
SWI I
POOL
PENCE
',UA71ER OF BTOttI ES NUMBER OF
SIGN
I
DWELLING
1
UNITS
DEMOLITION
IATURE
OF WO TO DE DONEJ,,
PRE -MOVE INSPECTION
Valuation
Fee Reeclpt No.
EXCAVATION OR FILL
Plan Check No .....................
til
J
BUILDING
RJ A l NS
4 PROPOSED U8
h
PLUMBING
G
U
/
117
PLOT PLAN (Indicate Building Setbacks, abutting street.)
HEAT & GAS LINE
9
PENCE
SIGN
I
RETAINING WALL
1
SWIMMING POOL
DEMOLITION
j
PRE -MOVE INSPECTION
EXCAVATION OR FILL
TOTAL AMODNT DUE
I hereby acknowledge that I have read this application; that the In.
/
torinntlan given Is correct; And that I am the owner, or the duly author.
ized agent of the owner. I agree to comply with city And state laws regu-
ATTENTION
APPLICATION APPROVAL
lating construction; and In doing the work authorized thereby, no person
will be employed In violation of the Labor Cade of the elate of Washington
THIS PER111T
application i9 nota permit until
relating to Workman's Compensation Ineurance.
AUTHORIZESThis
signed by the Building Official or his Dep-
NOTE: Permit Limit One Year (Except DEMOLITIONS which
ONLY TILE
WORK NOTED
uty; and fees are paid, and receipt is ae-
1
.hall be completed In ninety days; AlOVED-IN BUILDINGS shall be earn.
knowledged 1n, space provided.
l
pleled In six months.)
8161 E (OWNER OR AGENT) DATE SIGNED
INSPECTION
DEPARTMENT
DI R' S10 TURE
f
CITY OF
NOTE: Applicant Subject to Plan Check Fee
EDMONDS
DATE
/. S/
775-2825
Thls Per It covers nark to be done on prh'nte properly ONLY.
Ann rnn.l rnvllnn nn the nahlic dmmnw (enrhs, sldrwnike, dri-ways,
M11r vire a .vote tnl.slmt.
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