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THIS PERMIT AUTHORIZES ONLY THE WORK NO19M THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
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'APPLICANT, ON BEHAL 0 HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
ENG, INSPECTION FEE
ININTEREST, NDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
AGREES To
ANY AND
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TS OFFICIALS. EMPLOYEES, AND A ENTS FROM
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PLAN CHCCK DEPOSIT
RECEIPT
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ORDINANCE PROVISION.-
RECEI
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TOTAL AMOUNT DUE
ACKNOWLEDGE THAT I HAVE PEOAD HIS APPLICATION: THAT THE INFORMATION
APPLICATION APPROVAL
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I HEREB WT
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FOR INSPECTION
IN VIOLATION OF THE LABOR CODE OF THE STATE OF
18.27.
DATE
WORK?EN'VOMPENSAT INSURANCE AND ACW
-
CIGNA RE HER R 0 NT ATE SIINEO
(425)
OFFICIALS SIGNATUff
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771-0220
EXT 333
ATTtNTION
ITISUNL FULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
AW 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL.FlLE - YELLOW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. USC SECTION 109
FAX
PINK -OWNER - GOLD -ASSESSOR
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NUMBER
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PROGRESS INSPECTIONS PER UBC 1081FINAL INSP 1EO'D
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HEATSOURCE GLAZING % LOT LOPE M
PLAN CHECK NO: [VESTEO DATE
IZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
THE- C
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GRADINGIFILL
Bid IN (CURBS SIDEWALKS, DRIVFVWWS�,MAR1IU1ES, ETC.) WILL REQUIRE
SEPARATE PER SSION.
STATE SURCHARGE
PERMIT APPLICATION: 180 DAYS
P
'ERM'
PERMIT LIMIT, I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
I 'A I - P'
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
IS
'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIF1% ASSIGNS AND SUOCESORI
DEFEND AND HOLD HARMLESS THE CITY OF
END, INSPECTION FEE
LANDSCAP NG
IN INTEREST, AGREES TO INDEMNIFY.
G 0 E S 1 0 ANYAND
EDMONDS. WASHINGTMITS OFFICIALS. EMPLOYEES, AND AGENTS FROM
INSPECTION FEE
ALL. F -A A OFWHATEVEF NATURE, ARISING ORECTLYOR INDIRECTLY
AMAGE
AL 'MG OR 0 M CIE
LCLAIMSFOR BE
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M TH. ISSU G. , TH, IT $HALL NOT
FROM THE ISSUANCE OF T141S PERMIT. ISSUANCE OF THIS PER
OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
IS To MODIFY WAVEO'
DEEMEDTO MODIFY. WAIVE
PLAN CHECK DEPOSIT
'S AS 0 GE 'ROV'SI.IlI..
NOR LIMIT IN ANY WAY THE CITY LITY TO ENFORCE ANY ADMAN
OF Lt., NY W Y THE G"
TOTAL AMOUNT DUE
RECE1% -70
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFO MATION
APPLICATION APPROVAL
GIVEN IS CORRECT AND THAT I AM THE OVVNER� OR THE DULY AUTHORIZED AGENT OF
I I OWNER, I AGREE 10 COMPLY WITH CITY AND STATE L AWS REGULATING CONSTRUC-
CALL,
Bund`,�hq on"I"'an is not a ponall unlit signed Dy the
didmi or halber,00puall: and Fees am pled. and
THIOIN� AND IN DOING THE WORK AUTHORIZED TH ERE8Y, No PERSON WILL BE EMPLOYED
LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
mmo,j I, clum,aleded 1-0m. p—lood.
IN VIOLATION OF THE
WORKMEN'S,FOMPENSn�NSURANCE AND RCW 18.27,
OFFICIALS SIGNATURE DATE
IIONArA�Elnl
0 ATE SIGNED
(425)
;,_0 "y
771-0220
RELEASED B
EXT 333
77FANTION
\(—,
ITIS UNLAWFULTOUSE OR OCCUPY A BUILDING 08 STRUCTURE UNTIL
MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE - YELLOW - INSPECTOR
A FINAL INS P EcTiON HAS BEEN
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK -OWNER,- GOLD -ASSESSOR