20020389.pdfZ_
PERMIT EXPIRES
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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TELEPHONE
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NAME
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ADDRESS
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REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
CITY ZIP
ITIL11HONE
NAME
KENGINEERING
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REVIEWEDIDATE
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CARPORT ROC
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DESCRIBE WORK TO BE DONE
REMARKS ECTION REO'D
OGRESS INSPECTION$ PER UBC 108/FINAL INSP
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VALUATION I FEE
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IC IVEITED DATE
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PLUMBING
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY, ANY CONSTRUCTION ON THE PUBLIC
GRADINCIFILL
DOMAIN (CURBS, SIDEWALKS, DRIVEWAY% MAAOUEES� ETC.) WILL REQUIRE
SEPARATE PERMISSION.
.14AURVCHARGE
PERMIT APPLICATION! TOO DAYS
PERMITLIMIT.1 YEAR, PROVIDED WORK IS STARTED WITHIN 180DAYS
ENG. REV19W FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
�AFPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
ENG. INSPECTION FEE
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
LANDSCAPING
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
I ALLCLAIMSFOR DAMAGESOF WHATEVER,NATURE, ARISING DIRECTLY OR INDIRECTLY
INSPECTION PEE
CEIPT
x FROM THE ISSUANCE OF THIS PERMIT. SSUANCE OF THIS PERMIT $HALL NOT BE
DEEMED To MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
TO ENFORCE ANY GAIN NANCE PROVISION.
PLAN CHECK DEPOSIT
IR
NORLIVITINANY WAY THE CITY'S ABILITY
TOTAL AMOUNT DUE
I R CE
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
TI,'� A 1 A 1.1- 11 ��g bY Ih-
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THEOWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONST
TION; AND IN DING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
CALL
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Ofl,,j,j , h,,Iha, D�ly ald F 11, p1ld. Ild
IN VIOLA OR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION .,pt .dg.� In sPacG Pf-d0d
WORKME N INSURANCE AND RCW 18.27�
OF IG DATE
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(425)
715 /19/
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LRE&AAE6BY DrE
ATTENTION
EXT 333
IT IS UNLAWFUL TO U S E 0 R OCLY A 13UILDI NG 0 R STRUCTUR E UNTI
L
771-0221
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A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL FILE - YELLOW -INSPECT R
CATE OF OCCUPANCY HAS BEEN GRANTED, UBC SECTION 109
FAX
PINK - OWNER - GOLD - ASSESSOR
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CA
ENT
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NG
GARY HAAKENSON
CITY OF EDMONDS MAYOR
121 STH AVENUE NORTH EDMONDS.WA9802D - (425) 771-M FAX (4,25) 771-Ml
WebSite: wWW.CcedmondS.W&US
DEVELOPMENT SERVICES DEPARTMENT
tapZ Planning Building Engineering
16,2002
Charles Rezba
711 Alder Street
Edmonds, WA 98020
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RE: Encroachment Permit for Fence in City Right -of -Way
Dear Mr. Rezba:
I have spoken with your insurer (Hartford Insurance Co. ofthe Midwest) and they refuse
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to provide the City ofEdmonds with written cancellation notification ofyour insurance
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policy. This written notification is a minimum requirement for encroachment permit
approval-
In na,
A couple of options are available in order to move forward with this encroachment issue:
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1. Persuade your current insurance company to include cancellation notification to
the City ofEdmands on your existing policy (I am enclosing an example with the
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area in question highlighted),
2. Switch your insurance company, or
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3. Remove the fence from the City right -of-way.
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Please provide us with the required insurance certificate and/or inform the City ofyour
decision concerning the fence in the City right-of-way on or before May 31, 2002.
If you have any questions please don't hesitate to contact me at (425) 771-0220.
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Sincerely,
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J. L. Graf
Building Official, City ofEdmonds
enclosure: insurance certificate example
Incorporated August 11, 1890
Sister City - Hekinan, Japan
DATE(MWDDNY)
A -CORD. CERTIFICATE OF LIABILI I Y INWHIA,
T",S.pER ,,COM2 RSSS.UE
ERT lICAT . �g ER OF dfr0d=
T S . ' Co. 0 A, HTS UPON THE'
PRODUCER F."N"I A.0 Fe NC No
Hot , ') HIS C '. ATE Do IT A.E , EXTEND OR
Hot 1R THIS CERTIFICA . y THE
TH T Co",, FF DEED 8 POLICIES BE
,.F COVE
ALI R E RAGE
A,
CtWOM RaMIONS 1-800-Q3-()5 INSURERS AFFORDING COVERAGE
CLAM 1-877-805-9918
I.su ERA,
INSURER a: HA
Fl---uRER C:
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INSURER D,
711 ALM ST I INSURER El
MM01W,WA 98=
COVERAGES I DINO
NrD NAMED ABC VE FOR TH 1:: 1:::� I) V PERICD I DICATED. NOTWITHSTANO 0
THE POLICIES OF INS ANC���Jj!,',�ll BEEN ISSUED TO THE INSURED NAME RESPECT I CH THIS CERTIFICATE MAY BE ISSUE R
UR M MOWHAVI, OF
ANY REQUIREMENT, T , 0, AN PCONTIRACTeORSOTSHDER DOCUMENT WITH RESPECT
E 0 N IS SUBJECT TO ALL R S, EXCLUSIONS AND CONDITIONS SUCH
F� 'UY THE LIC ES 0 SO IS HERM TH.
MAY PERTAIN, THE INSURA I i �,i�FOR13E
POLICIES AGGREGAT N REDUCED BY PAID CLA S. ON
LT TYPE OF INSURAIN Obal EACH OCCURRENCE "I
_9LENERALLIABILITY All
SOMMERCIAL GENERAL LIABILITY FIRE DAMAGE I I
EXP (A�y
MED Exp Anv on. iN,—I
CLAIMS MADE OCCUR
PERSONAL & ADY -URY
AGGREGATE
GENERAI S
55RBA 4-500
IT �1"ql�
COMBINED INGLE LIMIT S
_�UTOMOBIUE LIAGIUTY
ANY AUTO
BODILY INJU Y
ALL OWNED AUTOS (P., —I
SCHEDULED AUTOS I -UAl
flp0,?ILy--I
.'RED AUTOS
PROPERTY DAMAGE
I AUTO ONLY. EA ACUlUtl IS
F_�ARAGEUASI� EA ACC I I
G_ Y UTO OTHER THAN
ANY AUTO AUTO ONLY AGO 1
, .C.S
�XCESS LIABIUT�_
_.UP CI INS "Oe
CLA
OCCUR s
DED.C"BLS
RETENTION
TOFY` I.uT,
WORKERS COM ENSATION AND E&L EACH ACCI ENT S
EMPLOYEATUABILITY �jg
E '-DISEASE. POLICY LIMIT I
CF F
ES.FIl OcAnoN HICLESIEXCLUSIOI CIAL PROVISIONS
OF EU40=,WA I.S LI= AS AN AMITI INSUM-
IT is TMT = Civy
CERTIFICATE HOLDE AODMONAL INSURED L-1F' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLE
ATE TNEI�01� THE IIIUIlG INSURER WILL ENDEV01 TO MAIL � OAIS Wl-El,
CITY OF q*mw NOTICE To THE CERTIFICATE HOLDER NAMED To THE LEFT BUT FAILURE . To oO SO IN—
MW DIV021 5W AVE NUM IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INIUMER III ACENTS 01,
gem EFFE ATIVEE
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IMPORTANT
It the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be en clorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(4).
if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, cenan po ci s M Y
does not confer rights to the certificate
require an endorsement. A statement on this certificat a
holder in lieu of such enclorsement(s).
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DISCLAIMER
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The Certificate of Insuran-e on the reverse side of this form does not constitute a contract between
holder, nor. does it
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the issuing insurer(s), authorized representative or producer, and the certificate
the affordFd by the policies listed thereon.
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affirmatively or negatively amend. extend or alter coverage
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ACORD 25-S (7197)
FINAL PROJECT APPROVAL FORM
TO
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: —FIRE DEPARTMENT DATE —
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ENGINEERING DIVISION DATE
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PLANNING DIVISION DATE—
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PROJECT
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DESCRIPTION OF WORK TO BE INSPECTED
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A field inspection was conducted to determine final compliance with approved pla s
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denotes that there are no objections from the above signed Department to the release of
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PERFORMANCE BONDS and the granting of:
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GRANT FINAL PROJECT APPROVAL
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
ci Copy of CORRECTION NOTICE given to owner/contractor by inspector
2.
3.
RE_INSpECTED OUTSTANDING ISSUES GRANT FINAL PROJECT APPROVAL
Date— Sign_
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FINAL PR JECT AP ROVAL F
DATE:
NIEM0 TO. PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTNIENT DATE —
ENGINEERING DIVISION DATE-
73a49:::::pLANNING DIVISION DATE —
PROJECT
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PERMIT #Zf
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DESCRIPTION OF WORK TO BE INSPECTED-2,"A4
A field inspection was conducted to determine final compliance with approved plans. Final approval
ere are ROL objections from the above signed Department to the release. of
denotes that th
E BONDS and the granting of
MANCEB
-X GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
U copy of CONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
a Copy of cOIMECTION NOTICE given to owner/contractor by inspector
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2.
3.
RF-INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date. Sign_----�
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing...................... .
Wall.................
PlerlPorch .................
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Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
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Underground
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Rough -In ...................
Commercial Final
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HEATING:
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GasTest ....................
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Gas Piping
Equipment ................
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Commercial Final
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EXTERIOR SHEATHING
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NAILING ..........................
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FRAMING _ .....................
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FIRST FLOOR FRAMING
INSULATION ...................
Floor Insulation
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Wall Insulation
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Ceiling Insulation
SHEETROCK NAILING
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SPECIAL INSPECTION
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................