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ENG. REVIEW FEES
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DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
STATE SURCHARGE
SEPARATE PERMISSION.
PERMIT APPLICATION: IODDAYS
PERMITLIMIT.1 YEAR -PROVIDED WORK IS STARTED WITHIN 180DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
C,
-APPLICANT. ON BEHALF OF 111S OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
AGREES TO DEFEND AND HOLD HARMLESS THE CITY Of
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INSPECTION FEE
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2 E MONDS. WA HINGTON, TS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
LY
ALL CLAIMS FO'R DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
RECEIPT
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
ANYCITY ORDINANCE
PLAN CHECK DEPOSIT
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CITY S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
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TOTAL AMOU NT DU E
APPLICATIO14 A �AL
I H EREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION. THAT THE INFORkATION
OATH H
GIVEN IS CORRECT, AND THAT I AM THE OWNER. E DULY AUT ORIZED AGENT OF
WITH CITY AND STATE LAWS REGULATING C.I,I�TPUC
Th" Ippil-lon m P,
CALL Off,1 OnP�"
THEO HER, I ACRES TO COMPLY
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FO R INSPECTION
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WORKMEN'S COMPENSATION INSURA E-AND R W 10.27.
/OF ICIALS SIG A �E DA E
ATES133NEO (425) -,vy
ID
771-Mv 4ELEASED By D E
EXT 3;33
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTI L 771-0221
-A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSES�OR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX