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SEPARATE PEFUIIIISS�M.
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REVIEW FEES
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RECEII
TOTAL AMOUNT DUE
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APPL CATION APPROVAL
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GIVEN ISCORREOVAND THAT I AM THE OWNER. OR THE DULY A.1iI.F ED
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THEOWNER. IAGREETOCOMPLY WITH CITY AND STATE LAVifSREGULAtING CON AUC
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WORKMEN S COMPENS=URANCE AND RCW 18.27
OF ALS SIGNAIU DATE
SIGNA;U
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771-0220 DATE j
ATTENTION
EXT 1333
IT IS UNi-AWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
A FINAL INS ECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL -FILE YELLOW- INSPiCT&I
P PINK -OWNER GOLD
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX �ASSESSOFI
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