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ERMIT
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CONSTRUCTION PERMIT APPLICATION 'A'DORESS
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MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC GRADINGFILL
DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION. q
STATE SURCHARGE
PERMIT APPLICATION: "' DAYS
PERMIT LIMIT-. I YEAR - PROVIDE. WORK 1. STARTED WITHIN 180 DAYS ENG, REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
;APPLICANT ON BEHALF 0 F HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS ENG. INSPECTION FEE
N INTEREST. AGREES TO �NDEM IFY. DEFEND AND HOLD HARMLESS THE CITY OF 6
0 YANG
2 E MONDS. WASHINGTON. TS OF CIALS. EMPLOYEES. AND AGENTS FROM AN Nepi
ALLCLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIREC.
1 FR M THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE PLAN CHECK DEPOSIT
. OEMEDT MODIFYWAIIEO REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
DE 'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION
0 NOR LIMIT ION ANYWAYTHE CITY "dPT
TOTAL AMOUNT DUE I.G I.L]
I HEREBY ACKNOWLEDGE THAT' HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF aa, a P.-A aadd a"a.
THEOWNER I AGREE To COMPLY WITH CITY AND STATE LAWS REGULATING CONSTALC CALL D,
C OYTED dly�. li,d Fl- - paid. ad
TIOKANDIN ONO THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPL acknowledgau ap.. p,,,,dd
VI I " 0 FOR INSPECTION
IN OLAT ON OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27 OFFI AILS SIGNATURE DATE
_:=WNEROIlfGENTj D E SIGNED (425) /o/z
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_&TENTION EXT 333
IT IS UNLAWFULTO USE 08 OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGII AL - FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FAX PINK OWNER GOLU- ASSESSOR
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OCT 17 2000
PROP DECKS. ISLSQ Fr
PROPGARAOR 360 BQ Fr
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ONNEFfCONTRACTOR IS RESPONSIBLE FOR
. ..........
-TO EROSION CONTROL AND DRAINAGE
PA
WATER SERVICE INSPECTIONS
771-1235
7EMPORARY CONSTRUCTION ENTRANCE (PER DETAIL)
STANDAhD DRAINAGE DETENTjJN SYSTEM
WORKSHEET
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CALC]ly. 'Doti,
ADDRESS 17508 7jo FL. PHONE: (4?c.-) 742 - 4� Sno
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..... DESIGN DA TA
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IMPERVIOUS AREA PIPE'DIA
PIPE LG ORIFIC.E
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NOTES.
1. Call Engineering DlvbiatL (n I.OX10) for R lightliao and detentioa sYM14M inspection
before backrilling And for fluml impecdoax. APPROVED BY
2. Raspowtibillity for operation and malatanam ofdralcage zyV=3 On privem pmpem is the
'blUtyofiluipropartyamar. Wlaritl iiccumulded in, the stoma* pipe muft be fluAhbd
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Project Review Checklist
Project Name: g;eJqAJ 7- . Plan Check #: 64�
ProjectAddress: /7,5/-,Q 2Z 6K)44�--- Id Receipt Date:
Underground Wiring Required
Hydraulics Permit
Plat/Subdivision Requirements
Street Dedications 421JE PUBLIC WORKS DEPT
Easements mftblic/Private
Engineering Storm Drain Review Feel
Engineering 2.2 Inspection Fee
Drainage Plan (On -site)
Setback - Storm Drain Line
Open Ditch - Existing
Culvert Required
Culvert Size
Shoulder Drainage/Shale Open Runoff.
Catch Basin Required
Driveway Slope & Vehicle Access ACAIZ
Sidewalk Required
Curb & Gutter Required
Curb Cut for Driveway Required
street Paving Required
Right -of -Way construction Permit Required YZ�5
Bond Required for Public hnP---ts
FEMA Map CheckfWater Table
Side Sewer Availability V65
Calculate Sewer Fee if No LID#
C" 0,
Water Meter Size
Water Meter Charge Required
S&ct Cut
Miscellaneous
RW Permit Date Issued
SS permit# Date Issued I fn
Meter Size Paid $ Date
C� r, v,,.e Ac(�
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Receipt#
Receipt #12-0=
Receipt # 1-7 1117,
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ACTUAL RIDGE ELEVATION
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SECOND FLOOR PLATE ELEVATION -
PREPARED BY
Name Title Date
DATUM POINT ELEVATION Co- 02 VERIFIED BY CITY BUILDING INSPECTOR V))
Name Date
L:\temp�building�handout�sfr\FieldHtCk.�d 8/00
FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: -FIRE DEPARTMENT DATE
ZAAtle (Le ICA f2:Z_ENGINEERING DIVISION DATE
PLANNING DIVISION DATE
PROJECT
SITE ADDRESS S_r AVe
DATEINSPECTED
PERMIT # �_20 0 ADB4
DESCRIPTION OF WORK TO BE INSPECTED
A field inspection was conducted to determine compliance with approved plans. Final approval denotes that
there are no objections from the above signed Department to the granting of:
-Final approval of the described work
I�GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
-FAILED FINAL INSPECTION - OUTSTANDING ISSUES
I
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
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RECORD OF INSPECTIONS
'X�
ATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAM /NAME OF BUSINESS
MAILI GAD RESS . 07 06 /J
0
10 TELEPHONE
NAME
rAMMM(c
ADDRESS
LAVOAC4 kU17/4�
CITY ZIP [�TLEPHONE
I
N-.Jl PERMIT EXPIRES
PERMIT 7
NUMBER ac)09-'—'l
JOB SUITE/A Tm
ADDRES� I 4��
P TNAMEISUBDIVISIONN.- I LOT NO/ LID NO.
- I e> —11 LID FEE
I PUBLICRIGHT OF WAY PER OFFICIAL ST FEET MAP PIP—
R P.114141 0
EXISTING TO PROPOSED
REQUIRED DEDICATION-4-- FT
zE NO. OF FIXTURES PRV RE.UIRE.
LA YES NO E3
REMARKS
0 NER�C04ACTOR RESPONSIBLE FOR EROSION CONTAOLIDRAINAGE
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ADD EBB
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STATE LICENSE NUMBER
AAM_�ST
X AD
74310
ENGINEERING R IEWEDIDAT
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FIRE REVIEWED By DATE
SHORELINE OR ADBN 'NSPEC
VA=E OR CU 'ON _NC-'
FIE O-TE
YE
SERA REVIEW
C MPLETE EXEMPT ALLOWED PROPOSED ALLOWED PROMED
E
NEW RESIDENTIAL P-..IN.1--C-
LOT C 1111AIE RECURRED SETBACKS (FT.) PROPOSED SETBACKS (FT)
ALLOWED ROPOSED FR T SIDE REAR FRONT URSIDE R�R
OMPLIANCE 09
JAROML 0 C USE
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ADDITION CHANGE OF
PAR NO LOT
REMODEL 0 APARTMENT 0 SIGN
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SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
GRADING)FILL
DOMAIN (CURBS.
SEPARATE PERMISSION.
STATE SURCHARGE
a PERMITAPPUCATIO : 160 DAYS
5
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
END. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SFOUDSE HDPA&ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
-
C)
IN INTEREST. AGREES TO INDEMNIFY. E EN �� 14 . RMLESS THE CITY OF
FROM ANYAND
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-MPLOYEES. AND AGENTS
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M P
E)EEMEDTOMODIyyAYWTAHIVECoRy7EADBUICEA Y REOUIREMENTOF ANY CITY ORDINANCE
IN CHECK 11 EPOSIT
NORpMI TtNANYW E IT S LITY TO ENFORCE ANYORDINANCE P VISION.'
0
I PT
TOTAL AMOUNT DUE
I HERE By DGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMAT10N
APPLICATION APPROVAL
=.EAN. THAT I A. THE OWNER. OR THE DULY AUTHORIZED AGENT OF
GIVEN INS E SRG
THE DW AND TATE LAW
ER. I AGREE To COMPLY WITH CITY - ULAT'MG CONSTRUC
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TION. A 0 THE WORK AUTHORIZED THE BY - PERSON WILL BE ENPL. TO
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FOR INSPECTION
IN VIC LAT 014 OF THE
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771-0220
�__TTENTION
RV
EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
OPI.I.M.-FILE YILLOW.1111PECTOR
GOLD -ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
SIDE
FAX PINK - OWNER
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