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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
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SEPARATE PEnmlSSION.
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PERMIT LIMIT. I YEAR
SEE BACK O� PINK PERMIT FOR MORE INFORMATION
ENG REVIEW FEES
;APPLICANT. ON BEHALF 05 HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
N INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD ARMLESS THE CITY 0 F
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RECEIPT
RECEIPT
I HEREBY ACKNOWLEDGE THAT: HAVE ISA. THIS APPLICATION: THAT THE IN50RMATION
GIVEN IS CORRECT. AND THAT AM THE OWNER. ORATHE U�Ly.AUTHGTI'INI�ED A�I�EIT 01
T E OWNER. I AGREE TO COMPLY WITH CITY AND ST E LAW EGLILA C. TRUC
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IION, AND,IN DOING THE WORK AUTHORIZED THENT
N VIOL T ON OF THE LABOR CODE OF TH E STA E OF WASHINGTON RELATING T
WORKMEN S COMPENSATION INSURANCE AND RCW 18,27,
SIGNATURE (OWNER OR AGENT) ATE SIGNED
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FOR INSPECTION
OFFICIA SIGNATU E DATE
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771-0220
RELEASED BY 0 TE
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A17ENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
EXT 333
771-0221
FAX
ORIGINAL FILE - YELLOW INSPECTOR
PINK OWNER - GOLD -ASSESSOR
S'98
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Agency Case
200000830
A..cv Use Um1Y
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Property Owner's
MailingAddress: El
C. Asbestos NJ
PUGET SOUND CLEAN AIR AUENU Y RE�CSIVML
110 Union Street, Suite 500, Seattle, WA 98101-2038
NOTICE OF INTENT MAY 2 6 2000
TO PERFORM: 4x101xY&0_"14
12 //1
I Pho
k; I State: LZ
Contractor
Contractor:
Affordable Abatement, Inc.
Mailing Address:
3732 Smith Ave., Unit B
ELL��
Phone:
City:
Everett
State: WA
Zi :
98201
Site
1—�'
IS—: WA
Zi
Address: 1 �3
I?D A
7, V
City.
Pro ect Manager or
at,45
Phone:
M;t�) 3,373 -7)"
Contact Person'.
q—)
E. sbestos Survey or No. of
Date Survey w
Li
— 0
Was Asbestos Found? e,
C3 IfNo, Attach Survey
El Marl Presumed: structures:
Expiration
AHERA Building
i U DIM
4 v, Certific w.
. r) A
q 4
Inspector Name:
aj,
F. Demolition No. of
Information: Structures:
----7r-77777��E HkN. kXl�
Demolition
Contractor: kA 2� .1
G. Asbestos Project I No. of Struz
Information: I (see back if>
Totai-ouantity to be �cmoved:
'e—al System Insulation: U Boi
S Fi_
��a_c . Man: I Livireprooll
Misc. Mat']: I LI Cement Ba. h9 Ct
Start 0- U i raining riyu kut- F
m-.-. — A /6+,= - r-I ordered Demolition (attach COPY of Order)
Start
-0 �'Urs: 9 41-1 -
Date:6- 5�-6 o DamteFlen""?-57-00 I
wit, all asbestos mater—
Ft. _L oved �brqject �com,
er
H. AsbestostDemolition Project C ategories:
Ncrtiftajrm Waiting Per!
3A L�EEE
_REF D
'ON�
FL —2L
I . ElAwner-Occupied, Single -Family Residence Asbestos Removal Proj ect
Prior Notice
11
ff, Sin le -Family Residence Demolition Pro ect
, ,
10 Da a
$150
,
2 0 , .01 Oil i er Demolitions With No Asbestos Removal Project
3 D s
$150
10 - 259 linear feet or - I square feet (see back of torm, for 0 tions
10 Da s
$300
" u
4 0 260 - 999 linear feet or IbU - 4 WY u feet
10
5. E] 1,000 - 9,999 linear feet or 5,000 - 49,9L99 u feet
1
0
000 - 49,999 linear feet or 50,001.) - 99.a are feet
V.
feet
Hi 31 ),000 - 99,999 linear feet or 100,00,1 - ,_ square feet
8. Ll 100,Uuu+ III
Twice P ct Fee
—7— ect
, [] Emergeqcy Asbestos Projector I I Emergency uentolition
Prior Notice
10-Da Review Period
TIN ice Project Fee
10. LJ Alternate means
Proj-1
Twice Prole -
s
Concurrent with
I do hereby certify that the information contained in this notification, and supplemental data described herein, is to the best of my co.p1cle— ReWew
Performed By,
knowledge accurate and complete. I shall not came or allow my asbestos project or demolition activities to begin until the appropriate
waiting period h I d
A rdable Abatement, Inc—
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PSAPCA Form No. 66-160 (Revised 4198) ACM
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The Puget Sound Air Pollution Control Agency (PSAPCA) is the local air pollution authority for Snohomish, King, Pierce and Kitsap
Counties. PSAPCA's Regulation III, Article 4, requires advance notification be submitted to PSAPCA, on Agency -approved form no.
66-160 (Revised 10/96), for any asbestos project involving materials equal to or greater in size than 10 linear feet or 48 square feet and
for any demolition project, regardless of asbestos content, involving structures with a projected roof area greater than 120 square feet.
Notices of Intent should be mailed or hand delivered to PSAPCA (address on reverse side) with the appropriate project fee. A
PSAPCA representative will review the notification, and if it is completed correctly a copy will be returned by mail within 3 to 5 days
to the mailing address entered in box C and box J. The returned copy will be your valid notification, Asbestos and demolition proiects
involving materials and structures below the notifleation thresholds listed above are still submect to all other requirements of PSAPCA
RegqLa��.
Demolition
Contractoi
O..,/CEO:
Mailing Addre.: 9
a-;, PM9 2�'(
Phone: (1-0� ) T)I - 727 0
Contractor's
Job 9:
Ci!y: E ) f-1 )� '�
I State: WA
[ Zig: 9(K C)a 0
Fax: �Z� ?)I - 2 / 0,7
GUIDELINES FOR SUBMITTING AN ASBESTOWDEMOLITION NOTIFICATION
Box A. Check the appropriate project type.
Box B. Enter the legal property owner information.
Box C. Enter the asbestos contractor information, or "not applicable" (N/A) for demolition projects when no asbestos -containing
materials are present. For an Owner Occupied, Single -Family Residence asbestos removal project (project category HI), list the
asbestos removal contractor or property owner doing the asbestos removal (include property owner's mailing address).
Box D. Enter the asbestos removal or demolition site address. For an Owner -Occupied, Single -Family Residence asbestos
removal project (project category HI) where the property owner's mailing address differs from the site address listed in Box
D, a letter must accompany the Notice of Intent verifying that the structure located at the site address is currently being used
as the property owner's domicile. Multiple asbestos/demolition projects involving more than one structure (project Category H2
through H8) must be submitted in accordance with PSAPCA Regulation 1, Section 4.03(a)(7).
Box E. Enter the asbestos survey information or check material presumed (for asbestos projects only). An AHERA building
inspector must conduct an asbestos survey prior to any demolition project (i.e., the wrecking, razing, leveling, dismantling or burning
ofa structure, making the structure permanently uninhabitable or unusable).
Box F. Enter the demolition project information. If the structure is to be used in a training fire, list the fire department responsible
for conducting the bum as the demolition contractor in Box J. If the property owner has been ordered to perform a demolition by
government official, submit a copy of the order from the appropriate official.
Box G. Enter all asbestos project information or enter "N/A" for demolition projects with no asbestos removal required. All multiple
structure asbestos projects (project category H10 and H 11) must be submitted with a work plan, map of the structures, complete site
address, type and amount of asbestos material to be removed from each structure, AHERA asbestos survey, and work schedule.
Box H. Check one project category in boxes I through 8. The project fee includes the demolition fee. Asbestos removal projects
and demolition with an asbestos removal involving less than 10 linear feet or 48 square feet may be filed as project category #3. An
emergency asbestos project or demolition may be requested by checking the appropriate job size category in boxes 42-9 and then
checking the applicable emergency box in category 09. Emergency asbestos project notifications must be submitted with a letter from
the property owner explaining the necessity for the emergency. Emergency demolition notifications must be submitted with a letter
from an authorized government official or a licensed structural engineer documenting that the structure is in imminent danger of
collapse. To request an alternative means of compliance for ftiable or notifiable materials, check the appropriate job size. category in
addition to the applicable box in categories 10 and 11. A work plan must be submitted by an appropriately trained individual along
with the notification.
Box 1. Sign the notification certifying the accuracy and completeness ofthe information provided on the form.
Box J. Enter demolition contractor mailing information (on back).
Mandatory amendments are required for changes that increase the project type, job size category, the types of asbestos materials to
be removed and work schedule changes. No fee is required for work schedule changes if the contractor is participating in the Agency
work schedule fax program. A $50.00 processing fee is required for all other amendments.
For technical assistance, contact Tom Hudson at (206) 689-4058, Larry Vaughn (206) 6894035 or Kwarne Agyei (206) 6894054.
For inquiries concerning notification and amendment status contact Anne Morgan (206) 6894090.
PSAPCA Fom No. 66-160 (Revised 4/98) ACM
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N
SITE TBM: ELFV 370.32
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ASBESTO -,TESY
I N C 0 R P 0 R A T E D
"GOOD FAITWASBESTOS SURVEY
19303 801h Ave. W., Edmonds, W
page I of4
IN#200419
April] 7, 2000
Nathan Construction
9792 Edmonds Way
PMB 266
Edmonds, WA 98020
Ph: 425-771-7270 Fax: 425-771-7105
Note: This house was occupied at the time ofthe survey, thus destructive sampl ingwas sornewha.t.1innited.-
io
u
h b
Ifthere is any additional located suspect ACM prior to or during demolition or reno c �ufcl
not limited to, those materials listed on page 2), that was not discovered in this survey, the material(s)
should be PACM unless tested oth
TM erwise by laboratory analysiss
INTRODUCTION
On April 14, 2000, Asbesto-Test personnel conducted a "good faith" asbestos survey (per
U.S.E.P.A./A.H.E.R.A. guidelines as designated and specified by Puget Sound Clean Air
Agency and Washington State) of the sinp_Le family dwelling and izaraffe In teda,19303W
Ava W., Editionds, Snohomish unty, Wash��This survey purpose is to identify any
Asbestos Containing Materials that may be present and will require professional removalprior to
renovation or demolition of the structures.
NARRA TIVE OF FIND
BASIC CONSTRUCTION (including siding and rooJing types): I he house is one story wood
frame on a concrete basement. The flat roofing materials were sampled. The exterior siding is
wood. There was no suspect ACM located beneath the wood siding exterior.
ATTIC/WALL INSULATION: There was no relating suspect ACM located.
PLUM33ING SYSTEM: There was no relating suspect ACM located.
*INTERIOR CONSTRUCTION, FMISKES, AND FLOORINGS: The interior is wood
and drywall. The drywall and taping materials were sampled. The acoustic ceiling tiles were also
sampled from the living room area. Vinyl and tile flooring materials were sampled per each
located homogenous area.
ELECT . RICALSYSTEM:- The electrical wiring insulation is of newer vintage and not of the
kind to be ACM and was not sampled. Any additional suspect electrical wiring insulation or any
suspect TSI (Thermal System Insulation) found in, around, or behind any locatedfise or
breaker boxes should be considered to be ACM (Asbestos Containing Material), unless
determined otherwise by laboratory analysis.
CONTINUETOPAGE2
8003 156th ST. SE - SNOHOMISH. WA 98296 - (425) 489-4040 - Seattle (206) 523-5117 Pager (206) 699-4Q9
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Page 2 of4 April 16, 2000
JN#200419 ANbcyto-Tesl, Ilia (425) 489-4040
19303 8011 Ave. W. Ednionds Snohomish Coun WaNhin'"Oft
HEATING AND VENTILATION SYSTEM There is an oil forced air furnace in the
basement. There was no visible ACM TS1 located on the furnace or ducting. Note: The furnace
and ducting; system should be thoroughly inspected by the asbestos abatement contractor as
there may be additional ACM TSI present that 6 concealed from view and not included in
this survey. Note: It was not possible to dismantle thefurnace and ducting to locate
andlor evaluate any additional suspect ACM which may be concealed or associated in
hidden areas. It is our opinion aryfurther handling ofthe heating system should be
coordinated by the project manager andlor abatement contractor. Ifany additional
relating suspect materials are locatedprior to andlor during any demolition or
renovation, any and all additional related suspect materials should be considered to be
ACM (Asbestos Containing Material), unless determined to be otherwise by laboratory
analysis.
ADDITIONAL BUILDINGS INCLUDED IN SURVEY: The garage is adjacent and behind
the house. The structure is wood frame on a concrete slab. The siding is wood. The flat roofing
was sampled.
Misc.: The window glazing materials were sampled from the garage and house.
*Some Fsample analyses listed may be a representative analysis ofindividual and separate samplings and
analysis ofhomogenous materials, as prescribed by A.H.E.R.A. protocol.
Samples taken are li sted with their corresponding analyses. Ifasbestos is detected, those samples
's
containing asbestos are listedfirst a d noted with the initials 'ACM
'a" 0,
, �i
If during demolition or renovation, any additional hidden or covered suspect materials similar to those
s
identified in the survey are located [may include but not limited to: sheet vinylflooring, tileflooring, wall
or ceiling resturings or paints, concrete siding or skirting, cement pipes, cement wallboard, electrical
cloth, electrical wiring insulation, thermal paper, wallboard, joint compounds, vinyl wall coverings,
I e should be treated as
spackling compounds, or any other suspect TS1 (71iormal SYstem Insulation)], h Y an
Asbestos Containing Materials unless determined to be non -asbestos by laboratory alYsis.
Note: Asbesto-Test, Inc. does not guarantee approximations of quantities ofACM., which maybe
listed with the analyses. it is therefore recommended professional abatement p ice and/or disposal
s r linear
quotes be obtained by inquiring as to fees per area ofspecific ACM material (i.e. quareo
foot, etc.), or by on site assessment.
Any and all materials idenitfled as ACM in this report must be abotedprior to ACM disturbance,
renovation, or demolitiam A licensedprofessional asbestos abatement contractor must do the asbestos
amity
abatement, ifthe structure is to undergo any kind ofdamolidion or renovation and is not a singlef
dwelling. Ifthe structure is a singlefamily dwelling and is to undergo demolition, any and all
materials identified as ACM must be professionally abated by a licensed asbestos abatement contractor
�, *W—Clures included in survey: two -one house one garage
,,s ..
s fic-than Construction
R
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ne er, B.Sc.
Inspector, certified ARERA.
accred.#CLAYS327 (Expires 8117/00)
CONTINLIETOIIAGE3 2-0
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Page 3 of 4 April 16, 2000
IN#200419 Asbesto-Test, Inc. (425) 489-4040
19303 80' Ave. W., Edmonds, Suohondsh County, Washing —ton
A ny and all materials Identified as A CM or PA CM in this report (andlor additional materials
associated with the structure that may be d1wovered and later identified as ACM or PACM),
must be professionally abated B YA LICENSED PROFESSIONAL ASBESTOS
ABA TEMENT CONTPU CTOR.
Note. Thefurnace and ducting system should be thoroughly inspected by the asbestos
abatement contractor as there may be ACM TSIpresent that is conceatedfrom view and not
included in this survey.
S4MPLES #146 AREASHESTOS CONTAININGUA TERIALS, �eepf the mastic as thled in sample 4. L
ANALYSIS ID ASBESTOSI/TYPEHQUANTITY OTHER MATE
1.0) sheet vinyl flooring yes // chrysotite n 45-50% non -fibrous materials,
kitchen -color: rust pebble cellulose
NOTE: The asbestos is in the gray -while vinyl backing.
The urastic is also ACM as it cannot be separated front the ACM sheet vinyl backing.
ApproiL 100 sq. ft.-on wood ACM
2.0) sheet vinyl flooring yes // chrysotile // 45-50% non -fibrous materials,
bathroom surface -color: orange pebble ACM cellulose
NOTE; The asbeslos is in the grito-while vinyl backing.
The mastic is also ACM as it cannot be separated from the ACM sheet vinyl backing.
3.0) tile flooring yes /I chrysotile 2-5% non -fibrous materials
bathroom 2" layer 9" x 9" tile -color: light brown
3.1) mastic -black yes H chrysotile 2-5% non -fibrous materials
ACM
BATHROOM IS APPROX. 25 SQ. Fr. _2NO LAYER IS ON WOOD
4.0) kitiolcum tile flooring yes // chrysotile // 2-5% non -fibrous materials
hall & SE bedroom 9" x 9" tile -color: brown streak
ACM
The asbestos is in the hard tile surface. APPROX. 125 SQ. 17117. on wood
4.1) mastic/backing-btack NAD tar, cellulose,
non -fibrous materials
5.0) flat roofing yes // chrysotile // 2-5% tar, cellulose, fiberglass,
over house ACM non -fibrous materials,
The asbestos is in the silver coat. The front part ofthe roof appears to have been tarred over the
silver coat as the asbestos is within the tar binder in this area. There is also a small shed -like
plumbing access at the back of the house about waist high (4'x 4') that has ACM silver coat on the
surface of the roof.
APPROX. 1370 SQ. FT.
6.0) flat roofing yes // chrysotile // 2-5% tar, cellulose, fiberglass,
over garage ACM non -fibrous materials
APPROX. 650 SQ. FT.
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Page 4 of 4
April 16, 2000
IN#200419 Asbesto-Test, Ina (425) 489-4040
19303 80"Ava W., Edmonds, Smihontish Countv, Washington
ANALYSIS ID ASBESTOSI/TYPEHQUANTITY
OTHER kTERIAL
WAS NO ASBESTOS DETECTED INANY OF THE REMAINING SAMPLES
THERE
7.0) acoustic ceffing tile NAD
cellulose, paint
living room
8.0) linoleum flooring NAD
cellulose, tar, fiberglass,
living room -color: gray fern pattern
non -fibrous materials
8.1) backingtonastic-black NAD
cellulose, tar
9,0) linoleum flooring NAD
cellulose, tar, fiberglass,
beneath plywood sub -floor in hall -color: brown
non -fibrous materials
9.1) backing/uLastic-black NAD
cellulose, tar
10.0) drywatl NAD
non -fibrous materials
10.1) drywaH taping compounds NAD
non_fibrous materials,
representative of 9 samplings
fiberglass
11.0) window giazing-house NAD
non -fibrous materials
12.0) wiLdow g, NAD
non -fibrous materials
_g-garage
t�,�. — (PLM)
analytical �7 SEPA 6001 116
j�L: ACM signifies "Asbestos Containing Material"
PACM signifies "Presumed Asbestos Containing Material"
CAR signifies "Concrete Asbestos Board"
significs"lesstha '
TSI signifies "Thermal System Insulation"
HVAC significs'*Heating Ventilating Air-Conditionine
NAD signifies "No Asbestos Detected"
**One percent is the USEPA regulatory limit for asbestos in bulk samples.
PLM hu been known Tomi. -bust- in —11 W,i6 cortain �bcstos, thus ouptive PLM mulmemnot be
guararaoc& Floor tilm raid %vipe, slould be tested with SEM or TEM, to insure auelYli�l amumey
when reporwd in sawl) Perwow9es
Asbesto-Test, Inc. claims responsibilityfor sample content only.
NOT TO SCAL
FB
N 4 El
80" A— W
A-110U ?B ENDOFREPORT
Me iieer
AA; F-4,
Ana#tical Chemist, B.Sc.
Alm round robin proficient
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Project Review Checklist R E C E I V E''D
JUN 0 '�' 2000
p LWW auW#: rbW=2-
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Project Address: 11-2-,U� 2U"- Reeipt Date:
Underground Wiring Required Y45_,5 /6",--
Hydraulics Permit
Plat/Subdivision Requirements 51P9q-it�5
Street Dedications
Easements - Public/Private 146-S 0A-le%25
Engineering Storm Drain Review Feel
Engineering 2.2 Inspection Fee
Drainage Plan (O-site) -!�M 15- P- 0161 - 165
Setback - Storm Drain Line
Open Ditch - Existing
culvert Required
Culvert Size
Shoulder Drainage/Shale Open Runoff
Catch Basin Required 100— I-P- "'I' It*
Driveway Slope & Vehicle Access oK
Sidewalk Required WIL 15-v-oi�kf5g-
Curb& Gutter Requi'red - S-?- -" -1bb
curb Cut for Driveway Required 1.4-
Street Paving Required UT,,'V14 F*"W
Right -of -Way construction Permit Required 4
Bond Required for Public Improvements 4E�5
FEMA Map CheckfWater Table
Side sewer Availability 4e;5
Calculate Sewer Fee ifNo LID#
Water Meter Size
Water Meter Charge Required
Hydrant Required
Street Cut
Miscellaneous
RW Permit #
SS Permit #
Meter Size _
Date Issued
Date Issued
Paid $ Date —
Receipt#
Receipt#
Receipt #
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ACTUAL RIDGE ELEVATION
It.W.
SECOND FLOOR PLATE ELEVATION
RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch .................
Z!
0
Retainlrig Wall ...........
0
Slab Insulation ..........
PLUMBING:
I -n
Underground .............
am
Rough -In ...................
IT!
Commercial Final
HEATING:
m z
Gas Test ....................
Gas Piping .................
Equipment .., ..............
Commercial Final
m m
EXTERIOR SHEATHING
NAILING ..........................
0
FRAMING ........................
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M 0
FIRST FLOOR FRAMING
INSULATION ...................
Floor Insulation
z
Wall Insulation
Ceiling Insulation
`4
SHEETROCK NAILING
0,
SPECIAL INSPECTION
M
MISCELLANEOUS ..........
FINAL APPROVAL FOR
—00
OCCUPANCY ..................
DATE 1101IVID�/
PERMIT EXPIRES,
ERMIT
P 'IRM I
CITY OF EDMONDS
U.
N BER
U
N M. E R =-2�
CONSTRUCTION PERMIT APPLI CATION
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SUITEJAPT#
SUITEJAPT#
ADDRESS
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7
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OWN RNAMENAME FBF
FI-AT NAMEISUBDIViSION NO,
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LOT No.
LID NO.
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LID FEE S
AILIN �ADDRESS
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ITY zip
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PAV REQUIRED
YES 0 NO 0
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ADDRESS
REMARKS
OWNERICONTR-0- --l"N C`NTR
CITY
ZIP TELEPHONE
FOE" -, I
NAME
AM p i Ll
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ENGINEEFIN.
ADDRESS
0
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FIRE REVIEWED BY DATE
CITY
ZIP T 5PHONE
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VARIANCE OR CU SHORELINE OR ADBN INSPEC ED-
9
STATE LICENSE NUM ER
EX
IRATON DATE CHECKEDBY
�'TION
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-
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SEPA REVIEW SIGN AREA HEIGHT
r ALLOWED PROPOSED ALLOWED PROPOSED
PROPERTY TAX ACCOUNI
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LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT)
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NEW
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c:
COMPLIANCE OR
0
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ADDITION,
CHANGE OF USE
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PLAN CHECK NO:
THIS PERMIT AUTHORIZES ONLYTHE WORK NOTED, THIS PER T COVERS WORK TO
BE ,I PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
SIDEWALKS, DRIVEWAY . MARQUEES. ETC.) WILL REQUIRE
.U..S. S RE
:1 SEPARATE PERMISSION.
PERM T APPLI CATO : ISO DAYS
PERMIT LIMIT: 1 411" ROVIDED W RK IS STARTED WITHIN TOO DAYS
YE P
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
OF
;APPLICANT,
N INTEREST, AGREES TO �NDEMNIPY. DEFEND AND HOLD HARMLESS THE CITY
FROM ANY AND
2 EDMONDS. WASHINGTON. TSOFFICIALS. EMPLOYEES. AND AGENTS
D, G SING DIRECTLYOR INDIRECTLY
ALLCILAIMSFOR MA ES OFWHATEVER NATURE, ARI
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIRE ME NT OF ANY CITY ORDINANCE
PROVISION.'
0 NOR LIMIT I N ANY WAY TH E CITY'S ABILITY TO ENFORCE ANY ORDINANCE
I HEREBY ACKNOWLEDGE T : HAVE READ THIS APPLICATION; THAT THE INFORMATION
H RIZED AGENT OF
GIVEN IS CORRECT. AND TH� AM THE OWNER. OR THE DULY A LITHO'
LAWS REGULATING CONS7RUC-
THEOWNE I AGREE To OMILYWITH CITY AND STATE
yi 0 PERSON WILL BE EMPLOYED
NO THE WORK AUTHORIZED THEREB N
Tl.�; AN. IN 001 TO
IN VOLATI ON OF THE LABOR CODE OF THE STATE 0 F WASHINGTON RELATING
WORKMEN'S COMPENSATION INSURANCE AND RCW I B*27,
SIGNATURE (OWNER OR AGI
DATE SIGNED
00
Z
Z
9
0
rn
VALUATION FEE
LAN CHECK FEE
BUILDING
PLUMBING
MECHANICAL
GR�DINGIFILL
.-W&CHARGE
ENG. REVIEW FEES
ENS, INSPECTION FEE
LANDSCAPING
INSPECTION FEE
RECEIPT
PLAN CHECK DEPOSIT
RE v
4 0�)
TOTAL AMOUNT DUE
27
APPLICATION APPROVAL
M 1-1 - 1-1- -" �'g— by Ihe
CALL
di his— Oe,V1,-d F.—r. p Id.
FOR INSPECTION
.jpj,—kIAdg.d m,... pr.
OFFMIA SIGNATU E DATE
(425)
t70
771-0220
D TE
RELFASEDSY-�>
ATTENTION IZA I 00,�
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
O.IGINAL-RLE YELLOW INSPECTOR
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- PINK - OWNER GOLD - ASSESSOR
k,lC,,AT,E OF OCCUPANCY HAS BEEN GRANTED� LISC SECTION 109 FAX
B
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