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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS —MIT COVERS WORK TO
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SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
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-APPLICANT. ON BEHALF OF HIS OR, SPEOUSE E',RSLA SIGNS AND SUCC6SORS
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FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL
OF ANY CITY ORDINANCE
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ABILITY TO ENFORCE ANY OPLIN—I,
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AFPLICATMN� THAT THE I ENDORMAT' -
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F . OR INSPECTION
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IN VIOLATION OF THE LABOR CODE OF THE STAT OF WASHINGTON RELATING
WORKMEN' INSURANCE AND RCW 18,27,
SIZ��RAG NT) DATE SIGNED
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771-0220
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PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT: AR - PROVIDED WORK IS STARTED WITHIN 100 DAYS
PER. I YE
'N. REV EW FEES
ENG. REVIEW FEES
SEE BACK OF INK PERMIT FOR MORE INFORMATION
ENG NEPE�T ON F�
ENG. INSPECTION FEE
ICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
Ap' CA
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I INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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EDMONDS
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE.ARISING 011— Ll —1-1.11.
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NB'ECT ON
INSPECTION
OF OS
DEPOSIT
RECEIPT /,/Y/ 0
. FROM THE ISSUANCE OF THIS
FROM TH
M DEEMED TO MODIFY, WAIVE OR REDUCE A Y REQUIREMENT OF ANY CITY ORDINANCE
DEEMED
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0 NOR L . T
RECEIP� ZI
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TOTAL AMOUNT DUE 1
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORM ION
APPL(CATION
APPROVAL
GIVE. CORRECT. AND THAT I AM THE OWNER OR THE DULY AUTHORIZED AGENT
IS
OF
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TION. AND IN DO NO THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE E LOYED
IN VIOLATION OF THE _ABOR CODE OF THE STATE OF WASHINGTON RELATING
TO
FOR INSPECTION
_d
ipj,kIld9. p,.,,d. d
WORKMEN S CgWRSATION INSURANCE AN. RCW 18,27.
OFFIQALS SIGNATURE DATE
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DATE SIGNED
(425)
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ATTER110N
EXT 333
IT IS UNLAVW�ULTO USE 013 OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
0 IGINAL FILE YELLOW INSPECTOR
A FINAL
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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