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STATE SURCHARGE
PERMIT APPLICATION: lall DAYS
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ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
UCANTj.0AN.lS`E`AL' OF g OR .. SPOUSE. EIRS. ASSI.NIS AND SUCCESORS
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IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON REL NO
WORKMEN'S COMPENSATION INSURANCE AND RGW 18.27.
E SIGNED
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SIGNATUF�,IQ
771-0220
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EXT 333
WENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
A FINAL I NSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
VALUATION I FEE
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APPLICATION APPROVAL
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S4PARATE PER�ISSIQN-.
PERMIT APPLICATION: iSO DAYS
PERMIT LIMIT'. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF 0 HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO NDEMNWY. DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMON A" NOT' TS OFFICIALS. EMPLOYEES. AND AGENTS PROM ANY AND
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VALUATION
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GIVEN I A. Y AND STATE LAWS REGULATING CONSTRUC
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THEOWNER. IAGREETOCOM PLY WITH
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THE STATE OF WASHINGTON RELATING TO
[FOR INSPECTION
IN VIOLATION OF THE LABOR CODE OF
WORKMEN" COMPENSATION iNSURANCEAND PCW IB27.
'SIGNATUI� NIER,&
'ED
(425)
771-0220
EXT 333
A:HENTION
IT IS LINILAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 10 9
FAX
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