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I In s FICH�RGE
PERMIT APPLICIT' N: lSo-AYS
PERMIT LIMIT. 1 YEAR . PROVIDED WORK IS STARTED WITHIN 180 DAYS
END REVIEW FE S
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
F HIS OR HER SPOUSE. HEIRS, ASSIGNS AN a sucCESoRS
;AP PLICANT. ON BEHALF HARMLESS THE CITY OF
DEFEND AND HOLD
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ENG. INSPECTION FEE
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ALL CLAIMS FOR DAMAGES OF WHATEVER NAT URE. A�ISING DIREC
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— RECEIPT
THS PEI IT. ISSUANCE OF THIS PERMIT SHALL NOT
FROM M ANY CITY ORDINANCE
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THAT I READ.T"'AppTLHCEAII�oL�Y.TIITTHIINI RMATION
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I HEREBY ACKNOWLEDGE
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FOR INSPECTION
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IN V �OLATIMN OF THE IABOR CODE OF THE STATE
INSURANCE AND RCW 18.27,
OFF CIAL5 SIGNA L) TE
Wol KMENE COMPENSATION
TESIGNED
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SIGNATURE OWNE N T))
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DAIE
771-0220
FIELEAS
EXT 333
ATTENTION
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 - YELLIW,IMSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
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CITY
VARIANCE OR OU SHOReUNE OR ADB. INIPEC!ION
STATE LICENSE NUMBER
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SERA REVIEW SIGN AREA HEIGHT
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BUILDING
DATE
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. '" S PERMIT COVERS WORK TD
L BE DONE ON ""ATE PROPERTY .L, ANY CONSTRUCTION ON THE PUBLIC
GRADINGIFILL
2 DOMAIN ICURBS, SIDE WALKS, DRIVEWAYS, MARQUEES, ETC.1 WILL REQUIRE
SEPARATE PERMISSION.
1� SURCHARGE
PERMIT APPLICATIONI� 180 DAYS
PERMIT LIMIT.- I YEAR - PROVIDED WORK 15 STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
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SEE BACK OF PINK PERMIT FOR ORE INFORMATION
HIS OR HER SPOUSE, HFIRS. A SSIGNS AND SUCCESORS
CITY OF
ENG, INSPECTION FEE
;A"PL"C�EISTilAI.Il�EILTF."
N NT R S INDEMNIFY. DEFEND AND HOLD H ARMLESS THE
ANY AND
LANDSCAPINNGEE
w EDMONDS. WASHINGTON Tl IFF� AE'. E.lL.YFES. AND AGENTS FROM
INDIRECTLY
INSPECTIO
ALLCLAIMS FOR DAMAGE�CF WRA�E' NATURE. ARISING DIRECTLY OR
NOT BE
CE OF THIS PERMIT. ISSUANC 0
FROM THE ISSUAN F THIS PERMIT $HALL
D, DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
PLAN CHECK DEPOSIT
0 NOR LIMIT IN ANY WAY TH E CITY'S ABILITY TO E NFORCE ANY ORD NANG E PROVISION."
THAT I HAVE READ THIS APPLICATION: THAT HEINFORMATION
I HEREBY ACKNOWLEDGE
GIVE" IS CORRECT. AND THAT I A. THE OWNER OR THE DULY AUTHORIZED AGENT OF
THEOW'ER 'A.REET.O.�PLYW ITH CITY AND STATE LAWS REGULATING CONSTRUC
CALL
o,"F puty ,d Foo$ P",
oll.
ION: AND IN DOING THE WORK AUTHORIZED THEREBY. N PERSON WILL BE EMPLOYED
RELATING TO
FOR INSPECTIO IN ... tp— ... p,F d
IN VIOLATION OF THE LABOR CODE OF THE STATE OF"WASHINGTON
WORKMEN'S COMPENSATION INSURANCE AND ROW 18,27.
TL
lPICIALi'_SIGN
IIIN;,,
(425)
SIG
OD
DATE
771-0220
RELE A!E211
EXT 333
ATTENTION.
IT IS UNLAWFULTO USE OR'OCCUPY ABUILDIN G OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE YELLOW INSPECTOR
GOLD -ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTEE). UBC SECTION 109
FAX
PINK -OWNER
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