20030027.pdfI
DATE RECEIVED I
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
- - — I A
15 MAILING ADDRESS
I-R)a6s g2ovt�
CITY ZIP TELEPHONE
NAME
ADDRESS
CITY
NAME
CITY
STATE LICENSE NUMBER
ZIP
ZIP
PROPERTY TAX ACCOUNT PARCEL NO.
441 10/110
EXPIRATION
PERMITEXPIRES
USE PERMIT
ZONE NUMBER,-
12&V,; � Alc-52
JOB
SUITEIAPTI
ADDRESS
,W
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Parmit Required
Susan use Partnit R*Wd
EXISTING — PROPOSED
Inspection Required
Sidewalk Required
REQUIRED DEDICATION— FT
underground
Wiring required 13
METER SIZE
NO. OF FIXTURES
PRV REQUIRED
YESC3 NO [3
-1
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
LL, REMOVAL, OR
FIRE REVIEWED BY DATE
M
VARIANCE OR CU ORELINEORADB# 11,31NSPECTION I BOND
REO'D POSTED
YES 13NO is
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE . EXEMPT I ALLOWED . PROPOSED I ALLOWED , PROPOSED
NEW
��RESIDENTIAL
PLUMBING / MECH
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (Fr.)
FRONT SIDE REAR
PROPOSED SETBACKS (Fr.)
FRO NT LIR SIDE REAR I
ADDITION
0 COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
.
z
PARKING
LOT AREA
PLANNING REVIEWED BY DATE
REMODEL
muLnFAmiLy
SIGN
REQ`D
PROVIDED
I
REPAIR
GRADING
CYDS
FENCE
X FT)
[REMARKi
DEMOLISH
TANK
OTHER
oGARAGE
CARPORT
o RETAINING WALL
ROCKERY
0 FIRE SPRINKLER
FIRE ALARM
I[TYPE 0"SIE. BUSINESS OR ACTIVITY) EXPLAIN:
Ater ZbAUM,4-1
NUMBER NUMBER OF CRITICAL
OF I DWELLING AREAS
STORIES I I NUMBE=- J*00P
DESCRIBE WORK TO BE 1DQV_t'�
JIVJ��
HEAT SQURCE GLAZING % LOT SLOPE %
LA1It__ -S I I -
1A[ CHECK NO: I VESTED DATE
CHECKED BY JTYPE OF CONSTRUC'nON CODE OCCUPANT
GROUP
8PECIALIN8PECTION JAREA OCCUPANT
REQUIRED [] YE LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC IGO/FINAL INSPECTION REO'D
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
FEE Description
State Surcharge
vl� — I City Surcharge
FEE
THIS PERMIT AUTHORLMS ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONW. AM CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPAPATE PERMISSION.
t:
Engr. Review
PERMIT APPILICATION: 180 DAYS
IL PERMIT ILIMM I YEAR - PROVIDED WORK 15 STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
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
Landscapelnsp.
Total Amt. Due
Li
21 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
Recording Fee
Receipt #
I HEREBY 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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
CALL
It until signed by the
This application Is not a parrin as are paid, and
Building official or histher Deputy: and Fo
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt Is acknowledged In space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
DAT7
AG
SIGNATURE (OWNER 0 It")
DATE SIGNED
J25)
771-0220
REKA�Eb'BV 4)ATE
ATTENTIO
E)ff 13
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK - OWNER GOLD - ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES
GREEN - ACCOUNTING
FINAL PROM T APPROVAL FORM
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLZASH SIGN
ENGINEERING DIVISION DATE
PLANNING DIVISION DATE—
MAM SIGN
:T
PROJECT 7�1 A-lp
S"
SITE ADDRESS..�2=1 toll
TED —e-S
PERMIT B# DATE INSPEC
DESCRIPTION OF WORK TO BE INSPECTED
ed plans. Final approval
A field inspection was conducted to determine final compliance with approv
denotes.that there are no objections from the above signed Department to the release of
PERFORMANCE BONDS and the granting of:
GRANT FINAL PROJECT APPROVAL
TIN
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
a Copy of CONDITIONS given to owner/contractor by inspector
T�
FARED FINAL INSPECTION - OUTSTANDING ISSUES
Q Copy of CORRECTION NOTICE given to owner/contractor by inspector
2.
3.
RE-INSpECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Si
Date-
ocaprvl.doc.l:temp:bldg:formslO/01