20628 78TH PL W.PDFlill 11111111
6775
20628 78TH PL W
ADDRESS: 12?ua
TAX ACCOUNT/PARCEL NUMBER: 0 0 000 2D 0
BUILDING PERNUT (NEW STRUCTURE):
COVENANTS (RECORDED) FOR:
CRITICAL AREAS: 194- -7 �3 DETERMINATION: F] Conditional Waiver [] Study Required Xwaiver
DISCRETIONARY PERMIT #'S:
DRAINAGE PLAN DA
PARKING AGREEMENTS DATED:
EASEMENT(S) RECORDED FOR:
PERMITS (OTHER):
PLANNING DATA CHECKLIST DATED:
SCALED PLOT PLAN DATED: 51-1
SEWER LID FEE $: LID
SHORT PLAT FILE: LOT: BLOCK:
SIDE SEWER AS BUILT DATED:
SOILS REPORT DATED:
STREET USE / ENCROACHMENT PERMIT #:
WATER METER TAP CARD DATED:
OTHER:
LATEMP\DSrs\Forms\Sbwt File ChecklisLdoc
APPROVED BY PLANNING*��
HEIGHT CALCS
IMPERVIOUS SURFACE CALCS
A = +99
EXIST'& ROOF OUTLINE 2533
8= +99
EXIST'& ' DRIVEWAY 474'S.F.
C +98.5
EXIST'& PATIO & POOL 1904 S.F." '
1) +99
PROPOSED ADDITION 253 S.F.
AVG GRADE = 98.8
PROP. HEIGHT 113
MAX. ALLOWED 124.1 13' 24' EXIST'&
NEW
+98.5'
99.33' N890 41' 10" W
OaSTING WOOD FENC E
A
0
+99
+98.5'
C
B
5WIMMIKIIA
w
roct
a%
00
00
0
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�XJ51'JNCI CO,,AC4r
8 198-7
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------------ - ---- :,-j
1) - - .. .. - -,-,: � - -- +9�
+99
BaSTING WOOD FENCE
N890 41' 10" W 99.3�
Leaal bescrit)tion:
Jackson Park BLK 000 D-00 LOT 2
Tax Parcel I.D. No.
00 4811 000 002 00
Lot Area 8741 S.F.
Lot Coverage Existi 2268 S.F. (25.9%)
Lot Coverage Propose9d 2521 S.F. (28.8%)
Lot Slope < 2%
North
Scale
1" = 20'
PROPOSED ADDITION FOP.
Joe Clements
'210628 78TH PL W
EDMONDS WA 9aC
20'
w
Go
00
W
0
0
ORA;
EXIST
CONC.
DRIVE
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0
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REFERENCE ELE
CORNER OF DA
0
i a:
q:
cc CD
Lu
M
f%ar t I
a i REr-wr FILE
ZONE R58000
FRONT SETBACK
SIDE 5ET9ACK
REAR SETBACK 15'
RECEIVED
MAY 14 2004
PERMIT COUNTER
HEIGHT CALCS
IMPERVIOUS SURFACE CALCS,
A = +99
EXIST'G ROOF OUTLINE 2533-5-77
B= +99
EXIST'& DRIVEWAY 474 S.F.
C = +98.5
EXIST'G, PATIO & POOL 1904 S.F.
0 = +99
PROPOSED ADDITION 253 S.F.
AVG GRADE = 98.8
PROP. HEIGHT 113
MAX. ALLOWED 124.1
L 13 24' EXIST'& I
0
PROPOSED ADDITION FOR
Joe Clements
20628 78TH PL W
EDMONDS WA 98026
20'
CLGAOMA 9*�Qlt> 0jr"jj NEW
uwrr_ T4614� or etc Q, 69AMOR-
St w er +98.5' N890 41' 10" W
E)aSTING WOOD FENC 7—T—
fo I
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Ft en C� k
---- I P� b
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Lai
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X I --- r I f il_-, 61AJI, tl
qS-7 L
00 +99
I Ickahov,
VaSTING WOOD FENCE
N89* 41' 10" W
Legal Description:
Jackson Park SLK 000 0-00 LOT 2
Tax Parcel I.D. No.
00 4811 000 002 00
Lot Area 8741 S.F.
Lot Coverage Existing 2268 S.F. (25.9%)
Lot Coverage Proposed 2521 S.F. (28.8%)
Lot Slope < 2%
+99
- 8
+99
North
Scale
1" = 20
TR8ET Fi,l
Vr- LE
Ly
00
Go
Lu >
F--
CL
CM
z 00
REFERENCE ELEVI
EXIST CORNER OF D/W
CONC.
DRIVE
- 99'
RECtIVED
MAY 14 2004
PERMIT COUNTER
ZONE R58000
FRONT SETBACK 20'
SIDE SETBACK 75
REAP SETBACK 15
APPROVED AS NOTED
BY ENGINEERING
Tj&&� - , k, ", ,
Date: - / -,z 2 12. w
v
Joe G. Clements 0 0
20628 78h Place West
Edmonds WA. 98026
(425) 771-4359
To: City of Edmonds
From: Joe Clements,
Re: Percentage of Drainable Land Subject to (ECDC) (Chapter 18.30)
1. 1 am applying for a—Wkfin
Master bedroom and bath
of adding a 247 sq. ft.
w-eadstina residence. This
is less square footage-tKain the 2000 square feet threshold
information-Wiletin #E-21 as, needing a drainage plan.
2. Eyisting drainage is provided by splash blocks for the comers of the house,
underground 4" plastic slotted pipe for the front of the house, and a 25' long x
3' Wde x 3' deep French drain that serves a channel drain in front of the
garage, and a box drain fbr the pool deck.
3. Gutters for the new addition can be tied into eAsting guffers on the South
side, and utilize a splash block on the North side.
RECEIVED
MAY 14 2004
PERMIT COUNTER
#P20 CA File No:
Critical Areas Checklist
Site Information (soils/topography/hyclrology/vegetation)
1.. Site Address/Location: 0 6,2 S' -7 9 tv. Sq-oA6
2. Property Tax Account Number. 6 Ll 9 1) 0 00 0 0 2 0 0
�3. Approximate Site Size (acres or square feet):
4. Is this site currently developed?,& yes, — no.
If yes, how is. site developed?. SIAJ.r P&M11, �ss-'-dcnce kd d e -r r, &I V
V
5. Describe the general site topography. Check an that apply.
X - :Tlat less than 5-feet elevatioxi change over entire site.
RoMng*
MIT.
Steep:
slopes on site generally less
,(A,, rti*
distance
of 66-feet). ij
L4� �
slopes present on site of more than 15% and less than 30% (a vertical rise of 10-feet
over a horizontal distance of 33 tD 66-feet)� fj
jet it
pr=vft
I
grades of greater than 30% a v 0 over a
of less fim 33-feet).
Other (please describe):
6. Site contains areas of year-round standing water. /Y 1A Approx- DeptL-
7. site contains areas of seasonal standmg water. N I A Approx. Dep&-.
What season(s) of the year? N /A
8. Site is in the floodway N 0 floodplain A) o of a watercourse.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-round?
0 Flows are seasonal? No (What time of year? NI -A
10. Site is primarily. forested meadow ;shrubs mixed
urban landscaped (lawn, shrubs eo
11. Obvious wetland is present on site: 0
For City Staff Use Oidy
1. Plan Check NumLxr, if ficable?
2. Site is Zoned?.. IL T
3. SCS mapped soil type(s)? �4Ann'maj Urbal tee
4. Critical Areas inventory or CA. map indicates Crifral Area on site?
5. Site within designated earth subsidenm landslide hazard area? No.
D
S
>� Y7EQUIRED WAIVER
RPVfPWPd hv-- To
City. AEdmonds
Development Services Department
Planning Division
Phone: 425.771.0220
Fax: 425.771.0221
The Critical Areas Checklist contained on this form is to
be filled out by any person preparing a Development
Permit Application for the City of Edmonds prior to
his/her submitW of the application to the City. .
The purpose *of the Checklist is to enable City staff -to
determine whether any potential Critical Areas are, or
may be, present on the subject property. The information
needed to complete the, Checklist should be easily
APPUCAION P9 V L'®r
Date Rec=bd: [Ir I U
City Receipt#:. 6f LH -3 5
Critical Areas File #: 02406J4
Critical Areas Checklist Fee:. is
Date Mailed to Applicant,_
A property owner, or his/her authorized representative,
must'fill out the checklist, sign and date it, and submit it.
to the City. The City will review the checklist make a
precursory site visit and make a determination of the
subsequent steps necessary to complete a development
permit application.
Please submit a vicinity map, along with the signed copy
of this form to assist City staff in finding and locating the
specific piece of property described on this form.. In
addition, the applicant shall include other pertinerit
Information .(e.g. site plan, topography map, eft.) or
studies in conjunction with this Checklist to assistant staff
in completing their preliminary assessment of the site.
The undersigned applicant, and his/her/its heirs, and assigns, in consideration on the processing of the application agrees
to release, indemnify, defend and hold the City of Edmonds harmless fiom any and all damages, including reasonable
attorney's fees, arising fiom any action or mhwbon based in whole or part upon falw, misleading, inaccurate or
incomplete information fiirmshed by the applicant, his/her/its agents or employees.
By my signature, I certify that the information and exhibits herewith submitted an true and correct to the best of my
knowledge and that I am authorized to file this application on the behalf of the owner as listed below.
SiGNATuREoFAPPI.ICANTIAGENT J&? DATE
Property Owner's Authorizatlo�/
By my signature, I certify that I have authorized the above Applicant/Agent to apply for the sul:ject land use application,
and grant my permission for the public officials and the staff of the City of Edmonds to enter the sul�ject property for the
purposes of inspection and posting attendant to tins application.
SIGNATURE OF OWNER DATE
I PLEASE PRINT UtARLY
Owner/Applicant:
Toe 'and cind:x C1 er" e)ITS
Name. f
0 6 2, 1
Shvet Address
EJ P"Vy)ds WA. c), s, o
city State zip,
Telephone: (J12S ) -7 '2 'Y 3S q '
Applicant Representative:
Name
Street Address
city State zip
Telephone:
Ern�ail address (optional): 1 .0" o h eXi 0 e P e'QMe4Sr.Eznai1 Address (optional):
0
0
PLANNING DATA
NAME: J'dt 1 CIA V. Clf',e/al DATE: /1'1/-0'/
SITE ADDRESS: '. I an64F 79'31. fbict WC57- PLANCHK#: Qq-17q
PROJECT DESCRIPTION: AJdvr�a, L Anaarg/- bedrn,, I 6q�krov,—
REDUCED SITE PLAN PROVIDED?Oet No)
MAP PAGE: CORNER LOT: (Yes FLAG LOT: mems
ZONING: CRITICAL AREAS DETERMINATION M
El Studv Reaulred:
Uwwalver
El Conditional Waiver
SEPA DETERMINATION:
El Fee
El Checklist
UAPO list w/ notarized form
(,Needed for 500 . cubic yards of grading, Shoreline Area- site within 200 . ft. of Puget Sound or Lake Ballinger)
empt
SETBACKS:
Required Setbacks:
Street. X5 Left Side: "7 Right Side:_ 7 It( Rear:
Actual Setbacks: r e
SIJ6 .10
I
Street—:2"Or Left e: Right Side: ear:
Street map checkedY additionail ;etback required? ()Les No XDN-A%
Tr-7 5U OJ(.
dZETACHED STRUCTURES: 40
ruf \11 �63T-( Ta ;'we
LL"OCKERIES:
($VENCES/TRELLISES:
a BAY WINDOWS / PROJECTING MODULATION:
'9-STAIRS I DECKS:
PARKING: Required: �- Actual:.
LOT AREA: q. �7qt
LOT COVERAG E: M
Calculations: Zo
BUILDING HEIGHT:
Datum Point: Datum Elevation:
Maximum All wed: Actual Height: Iq
A.D.U. CREATED?: nNo I Yes)
SUBDIVISION: ^14
LEGAL NONCONFORMING LAND USE DETERMINATION ISSUED:
OTHER:
Plan Review By. (�3) (�ecA4\1 5'11 �lo Y
)v v�e 1,4ft,
NewBPPIanningDataForm.D0C
00
C)
LA
C I T Y ('E D M by*D S
For Inspection Call 771-3202
Address of Construction:
R-C
, t" mup-
, jAy 2 8 1987
pUBLIC WORKS
6 6 Q �- 7 0 7�,
Property Legal Description (Include all easements):
407 e ks or) &I k, k L41 'T �0
Owner and/or Builder: J0
Contractor & License No:
Single Family Residence
Multi -Family No. of Units
Commercial (No. of fixture Units
Sf E S E W E R
PERMIT NO.
R WIT--
07707
Invasion into City Right -of -Way: No L,--� Yes (If Yes, Right -of -Way
Construction Permit required. Call One -Call -Center (1-800-424-5555) before any
excavation.)
Cross other Private Property: N o L,-,� Yes — (If Yes, easement required,
attach legal description and county easement number.)
PLEASE READ THE ITEMS LISTED ON THE BACK
I certify that I have read and shall comply Date
w i I/
th the items listed on the back.
Permit Fee: Issued'By:
Trunk Charge: Date Issued:
Assessment Fee: Receipt No.: 11'a-51
Partial Inspection:
Comments Date Initial
Final Inspection Approved:
-7D--a ee___7 Initial
Rejected:
Reason —Fa—te Initial
** PERMIT MUST BE POSTED ON JOB SITE **
Wh.ite Copy - Fil,e Green Copy -'Inspector
Buff Copy - Applicant
—/7
z
The City of Edmonds
Side Sewer Drawing
EASEMENT NO - ----------------------------- -------------- .
NEW CONSTRUCTION a REPAIRS F-1 LID NO - ------------------ ASMT. NO . .................
OWNER ............................................. CONTRACTOR -51�EL- F ------------------------------------------------------------------- PERMIT NO. 6;�7-1-077
JOB ADDRESSD.-Q--(e--A-3 ...... 7-7 - ---------------------------------------------- LEGAL DESCRIPTION: LOT NO. ------------------------------- BLOCK NO - ------------------------------------
.......... k
--------------------------------------
i
C
t"E
NAMEOF ADDITION ------------------------------ ----------------------------------------------------------- - - ----------------------------
L�" eke WV-
q,,p.v.e,
?V-0- tto wit, 0
42'
V, c- 5 LV V. %.k e- S
-75 "1.- 7 �, - VNA. --
Approved:
*1 e�,e�
PWW-0001-11/75 (REV.11/78) DATE .................... By . ............................ ea- ...
7
NOTICE:
No warranty of accuracy.
The information shown on the attached
map(s) was compiled for use by the City of
Edmonds, its Employees an ' d Consultants.
The City of'Edmonds does not warrant the
accuracy of anything set for ' th on these
map(s). Any person or entity-reque sting a
copy should conduct an independent
inquiry regarding the information shown on
the map(s), including, but not limited to,
the location of any sewer stub shown. Such
sewer stubs may or may not exist and may
or may not exist at the.location shown.
Neither the City of Edmonds nor its
emp-l-o-yee-s or officers Shcall be liable for the
information given on this map(s), nor for
any one representation provided based
upon said map(s).
APPLICATION
M PlApt
for
City of Edmonds SIDE SEWER PEI�NIT EASEMENT No . .............. ....................
NEW CONSTRUCTION REPAIRS
L4 1
//Z) 1-j"
OWNER ...........
/
CONTRACTOR,-, .. . ......
2� PERMIT No.
ADDRESS! .. . ....
.. ........
..... . ........... ........ ...... )LEGAL
'I
DESCRIPTION� LOT No. ....Z
............................ ..... BLOCK No . .................. ........................
2 b to 2- gS 79 rH
NAME OF ADDITION .......... ..................................
IFT
Approved:
DATE ...
. ......... ................ By ...
-------------------- * ---------------------
�-'CIT-,Y"OF,,lEUMONDSI",,�.--.,
Can -Pjt�64j��v G-1167 wlien work
CIVIC CEIVTER.-�— WATEW SEWIM,�_� DEPAR
rmdy`q.W_��'
L" tions Saifiid",�SimdiW or iiolidais.) N2. 1881
--.'WEk RM
- S 10 F' -,,'S" t L '� !R I
.............
A-VenAe ... N.or .....................
.....................
Kenneth-.:.H.:� C4rito . n
QVVNER..� --------- - ---- : ------------- - ------ ------- 7 ------------------------- ------ - -----------
CONTRACTOR.q�YPPiC VieW P1Umbk1?g ......
- --------- ..................... ................
2:8 67
Permission is -NECT a. side sewer
---- ---------------------
granted . ...... ...... 19 .......... for ---------------------- days, to IREPAM or CON
with - ty Sewers in accordance with aPPILication on file and governing ordinances
ATTENTION IS CALLED TO THE FOLLOWING:
NOTE'No. 1—The owners OX �he property may obtain '�L permit to construct sewer inside property line. A licensed Side Sewer Contractor must
be employed to construct side sewer in street area- Do not cover any portion of sewer before It has been inspected.
No. 2--Obtain full Information regarding Ordi
nance 11.16.030 -and Regu�lations governing side sewers when. -you get permit.
NOTE No. 3—TqP of, side sewer must have at least 30L inches coverage at property line and 12 inches inside property line; mJnImum grade of 2%.
No ben ds' in grade sharper than % Will be
permitted.
.,,,NOTE No. 4—Trenches in street must be water settled and surface of street restored to original condition. Contractors shall be responsible for
failure, due to improper �,Work which may develop within one year of completion.
NOTE, No. 51—It is,unlawful to alter or. do any other work than is provided for In the permit, or to do any work on the main sewer or Its'ap-
purtenances except to insert the pipe Into the wye.
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CITY OF EDMONDS
PUBIAC WORKS — EWjINEERING
OTR q-tET ff, i- E
ACTION REPORT
M 1862
SUSPENSE DATE:
D ate: -3 Time:.- File #
Attachments: =Yes
F—INo
SUBJECT: r�:
REQUESTOR: NAME: _ TO
ADDRESS:
PHONE: 2 z z
REQUEST RECEIVED BY:
TELEPHONE
CONTACT IN OFFICE
OTHER:
RECEIVED BY:
ONITC Tn-
o-l"..
MMMMMM
UMMM=
=10���MLWRMMMM
MM
so
M101am
0001
ACTION: 7'Z6E-
All Concerned Notified
Action Completed/File
10
0
� ZIP
7 7
A��Iv 4�z
XN �,c
4(1
9c 0 S� 6
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AT FIL
DATE RECEIVED
PERMIT EXPIRES
CITY OF EDMONDS
USE PERMIT
ZONE jZt>(2�
NUMBE
CONSTRUCTION PERMIT APPLICATION
JOB APT#
ADDRESS '�Ob?� -71741"
R 0
OWNER NAME/NAME OF BUSINESS
PLAT NAME/SUBDIVISION NO.
77""
7
LID NO.
LID FEE
Tole- + Cind C_ I e m e j4 TS
u
MAILING ADDRESS
7-
-78, L'
TESCP Approved
206 99' rLace we.ST
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required
EXISTING — PROPOSED
Street Use Permit Recfd
Inspection Required
Sidewalk RZuked 13
CITY ZIP
TELEPHONE
jcdpn on 990 A 6
I/_? S
7)' / - -
REQUIRED DEDICATION- FT
UndwWoLmd
wiring req 13
NAME
METER SIZE LINE
SIZE
NO. OF FIXTURES
PRV REQUIRED
YES13 NO 0
ADDRESS
REMARKS
z
x
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
z
CITY ZIP
TELEPHONE
'"s
TNAME tvfier do0der
ZSL #
,3'0 IS C4. Co nj% C I e M e
E g4TE
'NeMEERING REV D B��;,,
103C
ADDRESS\
Gz�l 1/ye
.Q,06 fti' 7 g (A /C&
FIRE. -REVIEWED BY DATE
lu
CITY zli&
F—Jmcr)Js 290;L I
TELEPHONE
R;S) 777, j -AJ3_rg
0
0
It
rL
. , VARIANCE ORCU"'.
SHORELINE OR ADS#,;-
IN§PECTION
MgQ
BOND
P OSTED
f
STATE LICENSE NUMBER > EXPIRATION'DATE
—
CHECKED BY.
NIA
PkNO
$
SEPA REVIEW.,
COMPLETE E)K
SIGN EA,
ALLOWED PROPOSE
HEIGHT
��ALLO PRq-96EV
PROPERTY TAX ACCOUNT- PARCEL�NO.
00L/19)100000*A00
P
!: 1
NEW RESIDENTIAL PLUMBING MECH
—1 LOT COVERAGE
ALLOWED
REQUIRED SETBACKS fff�7
FRONT SIDE REAR
-PROPOSED SETBACKS (FT)
FRONJ, L/RSIDE REAR.,,
COMPLIANCE OR
'J0
PRIPQS
3 as.-t
/
7
ADDITION COMMERCIAL CHANGE OF USE
z
PARKING
Ry R TVIDED
r lqt7ql
LOT AREA
P 4NNING REVIE*Dc*
%L4Z
dATE
5 -11 - q/o q
REMODEL MULTIFAMILY SIGN
o FENCE,
REPAIR 13 CYDS X FT)
REMARKS
R,,^ �1_ -e
DEMOLISH TANK OTHER
1.
GARAGE RETAINING WALL" o" FIRE SPRINKLER
CARPORT ROCKERY. FIREALARM
z
(rYPE OF USE. BUSINESS EXP N
CHECKED BY
TYPEjO CTION
E,
OC CUPANT
A
GROUP
NUMBER
OF
NUMBER OF
DWELLING
CRITICAL V
AREAS
SPECIAL INSPECTION
OCCUPANT
8
0
STORIES
UNITS
NUMBERpI001—W75
REQUIRED [3 YES
JAREA
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
z
PROGRESS INSPECTIONS PER UBC'108/FINAL INSPECTION RE01D
"Ic 13" piasrer- hedeoohi /b4r h
a dd iriiitl
VALUATION,
751
6escriotion
�F EE
Description
FEE
Plan I;hec,k 0 k
g
State Surcharge
45V
,
HEAT SOURCE GLAZING % kOT�SLOPE %
I
J,
'61 '
�Buildin PRrmit i City Surcharge 115
PLAN CHECK NO: VESTED DATE
'�P
_lumbing-"!9 I C)o Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK N TED- THIS PERMIT covFRs WORK TO
t
a
BE DONE ON PRIVATE PROPERTY ONLX ANY CONSTRUCTION ON THE PUBILIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
1:
SEPARATE PERMISSION.
—
Engr. Review 0
PERMIT APPILICATION: 180 DAYS
CL
PERMIT LIMM I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review Plan Chk. Deposit 2— LIP
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection Receipt # z_q
IALL
CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
9
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY; WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
—
Landscapeinsp. Total Amt. Due 60
61,
0
NOR LIMIT IN ANY WAY THE CRY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
Recording Fee Receipt #
L
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION .
N 18
GIVE IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
APPLICATION A F
P
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
This application is not a permit until signed by the
CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
Building Offlclall or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
I
FOR INSPECTION receipt Is acknowledged In space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
G E$(Ow:NER AGENT) DATE SIGNED
SM
1 OFFICIALS SIGNATURE ATE
IQ
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771-0220
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R E B Y DATE
AKTTENTION
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off 1333 A
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
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A
FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCYHASBEENGRANTED., UBC SECTION 109
ORIGINAL -FILE - YELLOW- INSAEMAR
09/03 PINK - OWNER - GOLD - ASSESSOR
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