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DATE
W.RKMENLS COMPENSATION INSURANCE AND RCW 18.27
OFFIC ALS SIGNATURE
_j_IGNATURS (OWNER OR AD DATE SIGNED
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771-0220
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IT IS UNLAWFULTO USE OR OCCUPY ABUILDING 1111 STRUCTURE UNTIL 771-0221
I NS P ECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI
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STATE SURCHARGE
P P RM '.N. li. Ty.
PERMITLIMIT'. I YEAR -PROVIDED WORK IS STARTED WITHIN ISODAYS
END REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
-APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCC9SORS
ENG. INSPECTION FEE
IN NTEREST. AGREES TO INDEMNIFY. DEF NO AND HOLD HARMLESS THE CITY OF
LANDSCAPING
2 EDMONDS, WASHINGTON. ITS OFF IALS. EEMPLOYEES, AND AGENTS FROM ANY AND
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INSPECTION FEE
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OF THIS PERMIT SHALL NOT BE
CHECK DEPOSIT
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MIT 1,
FROM THE ISSUANCE OF THIS PER SUANCE
DEEMEDT MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0
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0
LNT DUE
RECEIPT
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THATTH51NF RMATION
APPLICATION APPROVAL
GIVEN IS CORRECT. AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF
T lPlU'klY:` un"a a',,n.d
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC'
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T DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
ION AND IN
SHINGTON RELATING TO
F OR INSPECTION
,.,,pt,s a.k..wl0d9ld 'a.p... p—idod.
I N V16LATION OF THE LABOR CODE OF THE STATE OF WA
WORKMENS COMPENSATION INSURANCE AND RCW 18.27.
0 LS SIGNATURE DATE
IATE SIGNED
(425)
SIGNATURE (OWNER 01 AGE
771-0220
EXT 333
RILE ' /DATE
ATTENTION
UNLAWFUL TO USE OR OCCUPY A BUIIDING OR STRUCTURE UNTIL
771-0221
IT IS
A FINAL NSPECTION HAS BEEN MADE AND APPROVAL OR,A CERTIFI-
I
ORIGINAL -FILE YELLOW INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 09
FAX
PINK - OWNER GOLD - ASSESSOR