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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
UREDONEON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
MAIN (CURBS. SIDEWALKS. DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE P RMISSION
PERMIT APPLICATION; 180DAYS
PERMIT LIMIT. I YEAR . PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
GRADING1111.1-
STATE SURCHARGE
ENG . REVIEW FEES
;AP'INLI�C.A�.T�'O%EEHALI F HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
T A EST 0 AND HOLD HARM�ESS THE CITY OF
N ST AGREES T INDEMNIFY. DEFE
NO
NDS�,AS",A.,TN Tg.FFIDIA.LE. EVILOY�., ANDA.ENTS FROM ANY AND
EOMO ATEV A NATURE, ARISING DIRECTLY OR INDIRECTLY
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FROMTHEISSUA CEOFTHISPEAMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
ALLCLA'M .AD N AGE,10 LICE ANY REQUIREMENT OF ANY CITY ORDINANCE
DEEMED T01OD'Fy�yWAIVEC0q D 'C'
OR LIMIT IN ANY ITY�SEABILITY TO ENFORCE ANY ORDINAN
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TOTAL AMOUNT DUE
I HEREBY ACKNOWLEDGE T.ATI HAVE READ THIS APPUCATION� TMATTHE INFORMATION
OF
GIVEN Is CORRECT. AND THAT I AM C
THE OWNER, OR THE DULY AUTHORIZED AGENT 'd
THE OWNER, AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
Y ED
TION. AND IN DOING T E WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYT
H F WASHINGTON RELATING TO
IN VIOLATION OF THE LABOR CODE OF THE STATE 0
'ION INSJANCE AND ACW 18,27,
IS
S:!!�AGEN�/( DA171GNED
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APPLICATION APPROVAL
CALL D I,— I 1119— b, 111.
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FOR INSPECTION ,.pI il 11k11wI*dgod C0 ;,d.
0 ICIALS.SIGNATU DATE
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771-0220 um'&Aafi)
LEAS By
A17ENTION
EXT 1333
ITIS UNLAWFULTO USEOR OCCUPYABUILDING OR STRUCTURE UNTIL 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL -FILE - YELLOW - INSPECTOR
PINK -OWNER - GOLD -ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX
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