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City of Edmonds
Development Services Department
Planning Division
Phone: 425.771.0220
Fax: 425.771.0221
DATED RECEIVED:
CITYRECEIPT#: /7-/*-4,3
Critical Areas File #:. C?00/— 00.3 tz'
Critical Areas Checklist Fee: $45.00
DATE MAILED TO APPLICANT:.,:5—c;ZR-.;bO
.CRITICAL AREAS CHECKLIST
The Critical Areas Checklist contained on this form is
to be filled out by any person preparing a Development
Perrnit Application for the City of Edmonds prior to
histher submittal of a development permit 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 available from observations of the site 'or data
available at City Hall (Critical areas inventories, maps,
or soil surveys).
An applicant, or his/or 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 subn-dt 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
pertinent information (e.g. site plan� topography map,
etc.) or studies in conjunction with this Checklist to
assistant staff in completing their preliminary
assessment of the site.
I have completed the attached CRITICAL AREAS CHECKLIST and attest that the answers provided are
factual to the best of my knowledge (fill out the appropriate column below.).
.:....:-PLEASE PRINT CLEARLY
Owner/Applicant:
Le -
Name
D Z Wel ploce We<J
Street Address
WC, 0 �_O.
city State Zip
Telephone: 5 `7 7 9� `8
ZX4�il pa AW_U1_-_J
Signature Date:
Applicant Representative:
Name APR 1 200,
PERmi r Q "
Street Address %'QJVJ ER
city State Zip
Telephone:
Signature
Date:
vi(L V'��'\\ Vy&�'-&tu
411) 12 fe
0: harcUb� dildsTublic Handouts\ Critical Arcas ChecUst Doc/1-16-2
ot
6ih6 VA0 bNm�
Critical Areas Checklist CA File No:_Ll_.�36
Site Information (sofls/topography/`hydrology/ve�,etation)
1. Site Address/ Location: 7- Fictce- Uas:�
2. Property Tax Account Number. PArce( A6,,,6q/\
3. Approximate Site Size (acres or sq�ua?re . Oet): 301 n 0 0
4. Is this site currently developed? v
— yes; _ no.
If yes; how is site developed? - hone CeS-lcl' I �L
v
5. Desc ibe e general site topography. Check all that apply.
7�Flat less than 5-feet elevation' change over entire site.
Rolling: slopes on site generally less than 15% (a vertical rise of 10-feet over a horizontal
distance of 66-feet).
Hilly: slopes present on site of more than 15% and less than 30% a vertical rise of 10-feet
over a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of 10-feet over a horizontal
distance of less than 33-feet).
Other (pilease- describe):.
6. Site contains areas of year-round standing water: N c) Approx. Depth:
7. Site contains areas of seasonal standing water: 0 Approx. Depth:
What season(s) of the year?
8. Site is in the floodway t4 0 floodplain of a water course.
9. Site cpnpins a creek or an area where water flows across the grounds surface? Flows are year-round?
NQ Flows are seasonal? (What time of year?
10. Site is primarily: forested meadow -.shrubs mixed
urban landscaped 0awn,shrubs etc)
11. Obvious wetland is present on site:
,3-%ShamEibrmYTlannirqWo=Tublic: Handouts% Critical Areas Chediffist Doell-16-2001
36
Critical Areas Checklist CA File No: (9
Site Information (soils/ topography/ hydrology/ ve etation)
1. Site Address/ Location: 2.7-9-) � �� . I (-� Z_ kc e- k
2. Property Tax Account Number �Arce_(
3. Approximate Site Size (acres or sq�u�are.eet): — 301 Q 06
4. Is fi-ds site cuffently developed? V yes;_no.
If yes; how is site developed? 5)A�� h o m e- re5- f C/cw, 0"
V
5. Describe e general. site topography. Check all that apply.
less than 5-feet elevation change over entire site.
Flat
Rolling: slopes on site generally less than 15% (a vertical rise of 10-feet over a horizontal
distance of 66-feet).
Hilly: slopes present on site of more than 15% and less than 30% ( a vertical rise of 10-feet
over a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of 10-feet over a horizontal
distance of less than 33-feet).
Other (pleas6 describe):.
6. Site contains areas of year-round standing water: _N 0 Approx. Depth:
7. . Site contains areas of seasonal standing water: 0 Approx. Depth:
What season(s) of the year?
8. Site is in the floodway t4 0 floodplain of a water course.
9. Site cqnpins a creek or an area where water flows across the grounds surface? Flows are year-round?
N 0 —Flows are seasonal? m (What time of year?
10. Site is primarily: forested meadow —,shrubs mixed
urban landscaped Gawn,shrubs etc)
11. Obvious wetland is. present on site:
G'�Sham%ibrarY%Planningtr�x=\Public Handouts\ Cfitical Areas Checklist Docil.16-2001
City of Edmonds
Development Services Department
Planning Division
Phone: 425.771.0220
Fax: 425.771.0221
-DATED-RECEIVED: 2001
CITY REC EIPT#:
Critical Areas File #: aQ01— 00.3
Critical Areas Checklist Fee: $45.00
DATE MAILED TO APPLICANT:.,
.CRITICAL AREAS CHECKLIST
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 submittal of a development permit 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 available from observations of the site or data
available at City Hall (Critical areas inventories, maps,
or soil surveys).
An applicant, or his/or 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
pertinent information (e.g. site plan, topography map,
etc.) or studies in conjunction with this Checklist to
assistant staff in completing their preliminary
assessment of the site.
I have completed the attached CRITICAL AREAS CHECKLIST and attest that the answers provided are
factual to the best of my knowledge (fill out the appropriate column below).
PLEASE PRINT CLEARLY
Owner/Applicant:
Name
2--2- (a 1 (?�
Street Address
W 96 0 �_o
city State Zip
Telephone: Z5 `7 75 - 7 2�9V�
Signature Date:
Applicant Representative:
Name
Street Address
City State Zip
Telephone:
Signature
Date:
w(L
Glill yy�kc
are%ibrazy lanningbis blic Handouts\ Critical Areas Checklist Doc/1-1641Z
0)
0 Q �'c
bNYYS
Q
,77- T.7A
GUY of Edmonds
-OF-WAY CONSTRUC ION
RIGHT T
PERMIT
PermitNumber.
Issue Date:
A. Address or Vicinity of Construction: 22818 102 P1 W 9422941
8 --momp— C) Q5 B. Type of Work (be specific): - Tngtnll Npw Spryivp&�
9 0 - 1 9
C. Contractor: N-alt-ura-3 Gas Company
MailingAddress: 75 St SW' E3;@rgtt
State License #: 98203
D. Building Permit # (if applicable):
Contact: Frank Swan
Phone: 356-7500
Liability Insurance: Bond:$
Side Sewer Permit # (if applicable):
E. F] Commercial 0 Subdivision 0 City Project [M Utility (PUD, &E, WNG, CABLE, WATER)
E] Multi -Family [:] Single Family n Other
INSPECTOR: INSPECTOR:
__ � ------- M %I-- M ILT_ t__ C:-- Ty I'L---- t'
APPLICANT TO READ ANIL$IGN
�> !7�_/ damages, or
INDEMNITY. Applicant understands and by his signature to this application, agrees to ho-acity ofEdmonds harmless j,46;m injuries,
claims of any kind or description whatsoever, foreseen or unforeseen, that may be mage',against the City of Edmonds, or 7 o;f its departments or
employees, including or not limited to the defense of any legalproceedings including defe�tjqM6�44,�� attorney fees by reason f antingthispermit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MA TERJALSF,0,� A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATII 'F_EPS'ii�rABE HELD UNTIL PATCH
IS COMPLETED BY CITY FORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
Construction drawing of proposed work required with p'QrmiXppAcJatia
A 24 hour notice is required for inspection; Please call the Engineering Division, 771-0220.
Work and material is to be inspected during progress and at completion.
Restoration is to be in accordance with City Codes.
Street shall be kept clean at all times.
Traffic Control and Public Safety shall be in accordance with City regiilations as required by th6t ity Engineer.
All street cut ditches shall be patched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS.
Ihave read the above statements and understand thepermit requirements and thepink copy of thepermit will be
available on site at all * for inspection purposes.
Signature: _.dL0.'d �'P�A_' . .4 Date: December 2. 1994
_;7717o n- i - r - - Age- i�)�
racto or n
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY'1JSE ONU�
APPROVED BY: U. kA� "RIGHT OF WAY DEPOSIT
TIME AUTHORIZED: VOID AFT R DAYS—, DISRUPTION FEE/FUND III:
SPECIAL CONDITIONS: RESTORATION FEE:
COMMENTS:
,PERMIT FEE:
TOTAL FEE:
RECEIPT FEE:
DATE: ISSUED
NO WORK SHALL BEGIN PRIO R TO PERMIT ISSUANCE Eng. Div. 1994
FIELD INSPECTION NOTES
Comments:
Diagram.:
CONTRACTOR CALLED FOR INSPECTION
Partial Work Inspection by P.W.:
Work Disapproved By:
FINAL APPROVAL BY:
(Fund 111 - Route copy to Street Dept.)
El YES El NO
Date:
Date:
890 . 199-
Cfty of Edmonds
RIGHT-OF-WAY CONSTRUCTION
PERMIT Permk Nmba-
Issue Date:
A. Address or Vicinity of Construction: - 22818 102 P1 W 9422941
B. Type of Work (be specific): Tnrt-aii Npw qprviep_
C. Contractor- - WashLagton N-at-w-r-a-3 Gas Company
MailingAddress: 1172 75 St SW, Everett
State License #: 98203
D. Building Permit # (if applicable):
Contact: Frank Swan
Phone: 356-7500
Liability Insurance- Bond:$
Side Sewer Permit # (if applicable):
E. C] Commercial 0 Subdivision 0 City Project [3 Utility (PUD, GTE, WNG, CABLE, WATER)
E] Multi -Family 0 Single Family D Other
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cut 0 Yes JRNo G. Size of Cut: x H. Chargq_$
APPLICANT TO READ AND SIGN
INDEMNITY. Applicant understands and by his signature to this application, agrees to hold the City ofEdmonds harmless from injuries, damages, or
claim of any kind or description whatsoever, foreseen or unforeseen, that inay be nuute against the City of Edmonds, or any of its departments or
employees, including or not limited to the defense ofany legalproceedings including defense costs, and attorney fees by reason ofgranting thi8permit:
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL BE HELD UNTIL THE FINAL STREET PATCH
IS COMPLETED BY CITY FORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THEAPPLICANT.
Construction drawing of proposed work required with permit application.
A 24 hour notice is required for inspection; Please call the Engineering Division, 771-0220.
Work and material is to be inspected during progress and at completion.
Restoration is to be in accordance with City Codes.
Street shall be kept clean at all times.
7�-affic Control and Public Safety shall be in accordance with City regulations as required by the City Engineer.
All street cut ditches shall be patched with asphalt or City approved material prior to the end of the working day-'
NO EXCEPTIONS.
Ihave read the above statements and understand thepermit requirements and thepink copy of thepermit will be
available on sit purposes.
Signature: Date: December 2. 1994
60ontractor or �4gent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK -
FOR-CITY�USE ONLY
APPROVED BY:
TIME AUTHORIZED: VOID AFTER� DAYS... -
SPECIAL CONDITIONS:
RIGHT OF WAY DEPOSIT
DISRUPTION FEE/FUND., III:.
RESTORATION FEE:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE, Eng. Div. 1994
8 9 0 . 19 q -
Cit of Edmonds
Im y
RIGHT-OF-WAY CONSTRUCTION
PERMIT Permit Numlwr -
Inue Date:
A. Address or Vicinity of Construction: - 22818 102 P1 W 9422941
B. Type of Work (be specific): Tngtall Npw qprvirp
C. Contractor . WaShington N-at-ur-a-1 Gas Company
MailingAddress: 1199 75 St QW, vveratt
State License #: 98203
D. Building Permit # (if applicable):
Contact: Frank Swan
Phone: 356-7500
Liability Insurance- Bond:$
Side Sewer Permit # (if applicable):
E. E] Commercial []Subdivision City Project [3 Utility (PUD, GTE, WNG, CABLE, WATER)
0 Multi -Family [] Single Family Other
INSPECTOR: INSPECTOR:
F. Pavement or Concrete Cut: 0 Yes JUNo G. Size of, Cut: x H. Charge$
APPLICANT TO READ AND SIGN
INDEMNITY. Applicant understands and by his signature to this application, agrees to hold the City ofEdmonde harmless from irkft&Hes, damages, or
claim of any kind or description whatsoever, foreseen or unforeseen, that may be made against the City of FAlmonds, or any of its departments or
employees, including or not limited to the defense ofany legalproceeding8 including defense costs, and attorney fees by reason ofgranting this permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND ACCEPTANCE OF THE WORK ESTIMATED RESTORATION FEES WILL RE HELD UNTIL THE FINAL STREET PA7CH
IS COMPLETEO BY CITY FORCES, AT WHICH TIMEA DEBIT OR CREDIT WILL BEPROCESSED FOR ISSUANCE TO THEAPPLIC4NT.
Construction drawing of proposed work required with permit application.
A 24 hour notice is required for inspection; Please call the Engineering Division, 771-0220.
Work and material is to be inspected during progress and at completion.
Restoration is to be in accordance with City Codes.
Street shall be kept clean at all times.
Traffic Control and Public Safety shall be in accordance with City regulations as required by the City Engineer.
All street cut ditches shall be patched with asphalt or City approved material prior to the end of the working day;
NO EXCEPTIONS.
Ihave read the above statements and understand thepermit requirements and thepink copy of thepermit will be
�t.��s f, . t
available on site or i7sp
yc ion purposes.
Al, 67�t,,
Signature: Date: December 2. 1994
(Contractor or Agent)
CALL DIAL -A -DIG PRIOR TO BEGINNING WORK
FOR CITY USE 014�,:
NO WORK SHALL BEGIN PRIOR TO PERMIT ISSUANCE
Eng. Div. 1994
%A
NatuMlGas
A W-hno- E-ergy Ccnpaw
I
WNG to window
Watermain depth
gas main
4-41L-L
.... . .. .. .. . ....
Addendum to: City of Edmonds
Right of Way
Permit Application
Submitted by: Mariamne Kingsbury
b2gineering Aide
Washington Natural Gas
#356-7500 X7596
42 ?—':=I L�
Key:
-W- Water
-G- Gas
-SS- Sewer
-& Water hydrant
0 Water valve
Washington Natural Gas Company
1122 75th Street S.W., Everett, Washington 98203, (206) 355-3331
%A 2
WashmuligWWON
Nakn!WGas
AW-IWV-E--rWCOffpcYv
I
WNG to window
Watermain depth
gas main
72Z
All%
Addendum to: City of Edmonds
Right of Way
Permit Application
Submitted by: Mariamne Kingsbury
Engineering Aide
Washington Natural Gas
1356-7500 X7596
lzi -
942 0=1
-2- PL-- L'�-)
Key:
-W- Water
-G- Gas
-SS- Sewer
-e- Water hydrant
0 Water valve
Washington Natural Gas Company
1122 75th Street S.W., Everett, Washington 98203, (206) 355-3311
%A
NaturMGas
AW-"-Er-WComwv
I
WNG to window
Watermain depth
gas main
72
4-4iL-L
Addendum to: City of Edmonds
Right of Way
Permit Application
Submitted by: Mariamne Kingsbury
Engineering Aide
Washington Natural Gas
1356-7500 X7596
Key:
942 0=1 L�
-W-
Water
-G-
Gas
-SS-
Sewer
-&
Water hydrant
0
Water valve
Washington Natural Gas Company
1122 75th Street S.W., Everett, Washington 98203, (206) 355-3331
'Critical Areas Checklist
Site Information (soils/ topography/ hydrology/ ve etation)
1. Site Address/ Location: � Q,, t (-� Z_ A � I Cr_ e- k
CA File No:
2. Property Tax Account Number PArce-4 /Vu.t7a,-\ 446,1( 0'_ALd(A-2691�
1 11 1 1 1 1 1' , 1
3. Approximate Site Size (acres or sq�uVreee* 3011 (0 0 0
v
4. Is this site currently develope yes; — no.
If yes; how is site developed? hople rf5- t C/C� I
5. Describe e general site topography. Check all that apply.
Flat less than 5-feet elevation change over enV MAY 2 3 2001
Rolling: slopes on site generally less than 15% CaArw-rfj7tjaiWUGl0WontaI
distance of 66-feet).
Hilly: slopes present on site of more than 15% and less than 30% ( a vertical rise of 10-feet
over a horizontal distance of 33 to 66-feet).
Steep: grades of greater than 30% present on site (a vertical rise of 10-feet over a horizontal
distance of less than 33-feet).
Other (please describe):.
6. Site contains areas of year-round standing water: Nc> ; Approx. Depth:
7. Site contains areas of seasonal standing water: 0 Approx. Depth:
What season(s) of the year?
8. Site is in the floodway t4 0 floodplain of a water course.
9. Site contains a creek or an area where water flows across the grounds surface? Flows are year-round?
NIC) —Flows are seasonal? - (What time of year?
10. Site is primarily: forested . _; meadow shrubs mixed
urban landscaped (lawn,shrubs etc)
11. Obvious wedand is present on site:
G:\Shm\Library\PlamingTorms\Public Handouts\ Critical Areas Checklist Docti-16-2001
DATE RECEIVED
[7PERMIT EXPIRES
USE PERMIT I')
ZONE
CITY OF EDMONDS
NUMBER c<t
CONSTRUCTION PERMIT APPLICATION JOB SUITEIAPT4#
ADDRESS
BUSINfSS
OWNER NAME/NAME OF i'z
I , PLAT NAM E/SU BDIVI SION NO. LOT NO. LID NO.
um MAILING ADDRESS LID FEE $
TESCP Approved 0
RIGHT OF WAY PER FFICIAL STREET MAP
Q D 2. PUBLI 0
0. RW Permit Required 0
Street Use permit Req'd 0
CITY ZIP TELEPHONE EXISTING — PROPOSED Inspection Required 0
Sidewalk Required 0
C REQUIRED DEDICATION— FT Underground
Wiring required
7c.
0
NAME METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YES 0 NO 0 z
W
P ADDRESS REMARKS z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
z
W
,CITY ZIP; .%[YELEPHONE
+
NAME
ENGINEERING REVIEWED/DATE
ADDRESS ,j
0
�4V,
FIRE REVIEWED BY DATE
l'- CITY ZIP TEL6PHN W
z
0
N U.
_x
STATE LICENSE NUMBER EXPIRATION DATE VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
REQ:D� POSTED
0 YES �,8� No
SEPA REVIEW SIGN AREA HbGHT
PROPERTY TAX ACCOUNT PARCEL NO.
COMPLETE EXEMPT ALLOWED PROPOSED .PROPOSED
ALLOWED
_j
"7 EXP
NEW E],-R'ESIDENTIAL LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
PLUMBING MECH ALLO P I OPOSED FRONT SIDE REAR FRONT UR SIDE REAR
E]4;DITION C] COMMERCIAL COMPLIANCE OR z
"I �)4> 1 .4. z
CHANGE OF USE 41 150 2
PARK.ING LOT AREA PLAN ING REVIEWE'D,-BY ",!DATE :3
REMODEL APARTMENT SIGN REQ'D I'PROVIDED 15, i it CL
GRADING
I , 2,0,
C3 FENCE X
REPAIR CYDS FT) REMARKS
— — _4 1) G_
DEMOLISH TANK OTHER
)A'I C,,�) j
GARAGE RETAIERING WALL
z CARPORT ROCK Y RENEWAL
P (TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
<:1 - A , , 1�). — CHECKED BY TYPE U TION CUPANT
�7(30 OC
GROUP
CRITICAL
uj NUMBER NUMBERbF
cc
0 y
M OF DWELLING AREAS SPECIAL INSPECTOR AREA,\,,t�": OCCUPANT
o STORIES UNITS NUMBER REQUIRED [3 YES LOAD
DESCRIBE WORI� TO BEDONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
g
- T)
0
A
A i� t
FEE
VALUATION
; ku1 4 C
k PLAN CHECK FEE
HEAT SOURCE
LOT SL I QPE % BUILDING ;2,
Y,
PLAN CHECK NO: VESTED DATE
PLUMBING
THIS PERMIT AUTHORIZES ONLY tHE WORK NOTED. THIS PERMIT C6VERS WORK TO MECHANICAL
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC) WILL REQUIRE GRADING/FILL
SEPARATE PERM
ISSION.
STATE SURCHARGE
W PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS ENG. REVIEW FEES X5
SEE BACK OF PINK PERMIT FOR MORE INFORMATION 0
U) "APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS ENG. INSPECTION FEE
W
j IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FRO LANDSCAPING
cr M ANY AND INSPECTION FEE
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE RECEIPT.
PLAN CHECK DEPOSIT
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION..
RECEIPT'
TOTAL AMOUNT DUE
P
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT AND THAT � AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF APPLICATION APPROVAL
THE OWNER. I AGREE To COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
This application is not a permit until signed by the
TION; AND IN DOING TH&WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Fees are paid. and
IN VIOLATION OF THE CAbOR CODE OF THESTAfE OF WASHINGTON,z RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATION I�SURANCE AND RCW 18.27.
OFFI9IXLS SIGNATURE DATE'�
.�IGNATURE,(bWNEA'�R AGENT)j, DATE SIGNED (425)
771-0220 RELEA
�a BY DATE
A17ENTION EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL U_ I I _� o
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI_ 771-0221
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EMPLO.YEE BENEFITS OF AMERICA INC.
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