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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION
APPROVAL
GIVEN RECT. A 0 THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
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WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
OF IAL IINATURE DATE
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DATE IrNED
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771-0220
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ATTEN'tION
EXT 333
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE - YELLOW - INSPECTOR
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SEPARATE PERMISSION.
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STATE SURCHARGE
PE MITAPPLICATION: 18DIDAYS
PERMIT LIMIT.- I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENO. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF OF HIS OF I HER SPOUSE, HORS. ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
IN INTEREST. AGREES TO INDEMNIFY DEFEND AND HOLD HARMLESS THE CITY OF
LANDSCAPIN
X EDMONDS, WASHINGTON. ITS OFFICIALS. EMPLOYEES. AND A02NTS FROM ANYAND
INSPECTION FEE
ALLCLAIMS FOR DAMAGES OFWHATEVER NATURE,ARISING ECTLYOR INDIRECTLY
Din
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
3 DEEMEDTO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANYCITY ORDINANCE
PLAN CHECK DEPOSIT
RECEIPT
01 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
TOTAL AMOUNT DUE
IRICIRPT
7,) 7
IHERE Y ACKNOWLEDGE THAT I HAVE READ THIS APPUCATION: THAT THE INFORMATION
GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
APPLICATION APPROVAL
T E OWNER. I AGREE TO COMPLY WITH CITY NO STATE LAWS REGULATING CONSTRUC.
CALL
TN. ppl-l- 1. 1 . p.-,t -il mg- 1,, ft
TION AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMP DYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
S,ildilq Offill-I 11 hil- Doputy: Ild F m Pa,d. .,d
FOR INSPECTION ... ipi i, ,kl�lald I, lip- p-dod.
WORKMEN'S COMPENSATION�J�SURANCE AND FOW 18.27.
OFFICIALS SIGNATURE DATE
SIGNATURE (OWNER OR AfGIENT11 DATE, SrNEO
(425)
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771-0220
RELEASED BY ATE
ATTENTION
EXT 333
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPFlbVAL OR A CERTIFI-
CO_kk�qRIGINAIL- FILE - YELLOW: INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
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