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USE / PERMIT
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BUILDING DEPARTMENT
Applicant Fill
12S ' yv NUMBER _ q
PERMIT APPLICATION
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RESIDENTIAL
NEW
❑ NON-RESIDENTIAL
❑
GAS
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SIGN
ADDRESS
IOCCUPANCY
NAME lOR NAME OF BUOINESB)
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PERMISSIBLEACTUAL
LOT COVERAOEs SD� LOT COVFAOE C
DEMOLISH
EXCAVATE
OR FILL
INS DSOVE
MAILING ADDRESS
WALL KING
FENCE
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TELEPHONE NZU(MyBER
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REQUIRED YARDS ROPOSED YARDS
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FRONT BIDE REAR FRONT 81DE REAR
MATURE OF WORK TO BE DONE
NAME
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IAL LOT VA IACE OCONUSE
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yEB 0 NO PERMIT NUMBER
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TELEPHONE NUMBER
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EXI8TING EET R/W ............ FT. DEFICIENCY THIS PROPERTY
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CHECKED BY
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TELEPHONE NUMBER
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-MOVE INSPECTION
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METER SIZE I SERVICE SIZE I CLEARANCE
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SPECIAL INSPECTOR R UIRED
GROUP
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RESIDENTIAL
NEW
❑ NON-RESIDENTIAL
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GAS
LINE
SIGN
❑ YES 7'
IOCCUPANCY
PLAN CHECK BY THIS SITE IS LOCATED IN THE CITY
-i;-�� OF EDMONDS. LOCAL SALES TAX
1 SHOULD BE CODED 31.04.
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ADD ❑
ALTER ❑
REPAIR
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DEMOLISH
EXCAVATE
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WALL KING
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JU&IBER OF STORIES
NUMBER OF
HEAT & GAB LINE
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DWELLING
UNITS
Valuation Fe. Rcco
MATURE OF WORK TO BE DONE
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PROPOSED USE
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HEAT & GAB LINE
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FENCE
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DEMOLITION
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-MOVE INSPECTION
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EXCAVATION OR FILL.
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TOTAL AMOUNT DUE
I hereby acknowledge that I have read this application; that the In-
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formation given Is onrrecU and lbut I am the owner, or the duly author-
Ixed agent of the owner. I agree to comply with city and elate laws regu-
ATTENTION
APPLICATION APPROVAL
lating conetmetlon; and In doing the work authorized thereby, no person
will be employed Ia violation or the Labor Code of the State or Washington
THIS PERMIT
This application is not a permit until
relating to Workmen's Compensation Insurance.
AUTHORIZES
signed by the Building Official or his Dep -
NOTE: Permit Limit One Year (Except DEMOLITIONS which
ONLTHE
ONLY
{YORK NOTED
uty; and fees are paid, and receipt is ac -
—'
shall be completed In ninety days; MOVED -IN BUILDINGS &hail be com.
knowledged in space provided.
pleted In six months.)
-
BIGNATURE (OWNER OR AGENT)
DATE 11113NEII
INSPECTION
IREC OR' eI NAT RE
7/1 3 7 5-
DEPARTMENT
/
CITY OF
EDMONDS
nATE
ATE: Applicant Subject to Van Check Fee
775-2525
This Permit savers work to Do dons on private property ONLY.
Any nm.t radion nn the P., domain (curb., nI1,n'aik,. drivewys, a
.ryui-r., , „III rranlre •el•arnlr I ml.elan.
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