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STATE LICENSE NUMBER EXPIRATION DATE
PROPERTY TAX ACCOUt4T Pj�RCa NO.
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING PROPOSED
LID FEE S
TESCPApprovea 13
RW Pernut Required 13
Street Use Pornin Required
Inspection Required 13
SideAjik Requited 13
Underground C3
REQUIRED DEDICATION FT Wiring required E3
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
REMARKS
OWNER/CONTRACTOR
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Building Permit
PLAN CHECK NO:
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
w PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
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APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EOM DS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.,
Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
CALL
FOR INSPECTION
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN 15 CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL HE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
(425)
SIGNATU E I q4R 0
R E (9yY AGENT):
DATE Sl GNED
771-0220
OCCUPANT
LOAD
FEE Description
State Surcharge
City Surcharge
Base Fee
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Due e;ib - ric
Receipt # 1,2
APPLICATION APPROVAL
This application is nota permit until signed by the
Building Official or his/her Deputy' and Fees are pa,d, and
receipt Acknowledged in space provided.
cjrlALS..&WbNLTJRE A I EATE
ATTENTION IZA L IJ JJ
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN mADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 f IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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ORIGINAL - FILE YELLOW - INSPECTOR
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DESCRIPTION OF WORK TO BE INSPECTED L)'ST- .0C-I::_0A,1M ISQ0 A.)q
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A Reld inspection was conducted to determine.compliance with approved plans. Final approval denotes that
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-RE-INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL.
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