20040504 (2).pdfDATE RECEIVED
C1W OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF,
./DSINESS
MAILING ADDRESS
CITY
NAME
ADDRESS
CITY
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STATE LICENSE NUMBER
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PROPERTY TAX ACCOUNT PARCEL NO
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PLUMBING / MECH
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COMPLIANCE OR
CHANGE OF USE
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MULTIFAMILY
SIGN
REPAIR
GRADING
CYDS
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DEMOLISH
TANK
OTHER
GARAGE
RETAININGWALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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NUMBER
NUMBER OF
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NUMBER
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UNITS
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PERMIT EXPIRES
USE
PERMIT
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NUMBER
JOB
SUITE/APT#
ADDRESS
PLAT NAME/SUBDIVISION NO
LOT NO,
LID NO.
LID FEE $
TrSCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL
STREET MAP
RW Permit Required
E3
Street Use Permit Prict'd
13
EXISTING - PROPOSED
inspection Required
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Sidewalk Required
13
REQUIRED DEDICATION-
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Underground
Wiring friquirel
METER SIZE
LINE SIZE
NO. OF FIXTURES
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PRV REQUIRED
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YES IJ NO 13
REMARKS
OWNER/CONTRACIOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERI
FIRE REVIEWED BY
VARIANCE OR CU
SEPA REVIEW
COMPLETE EXEMPT
EXP I
LOT COVERAGE
ALLOWED PROPOSED
DAT E
DATE
SHORELINE OR ADB# I INSPECTION I BOND
REO'D POSTED
OYES ONO S
FSIGN AREA HEIGHT
ALLOWED . PROPOSED I ALLOWED . PROPOSED
REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (Fr.)
FRONT SIDE REAR FRONT UR SIDE REAR
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PARKING LOT ��A PLANNING REVIEWED BY DATE
REO'D I PROVIDED I
AEMARKS
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CHECKED BY TYPE OF QONSTRUCTION Col*' OCCUPANT
GROUP
SPECIAL INSPECTION JAREA OCCUPANT
LOAD
REQUIRED [] YES
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D
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VALUATION
Description FEE Description FEE
Plan Check
State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit
City Surcharge
Base Fee
PLAN CHECK NO: VESTED DATE Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
*APPLICANI ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review
Plan Chk. Deposit
IN INTERE�T, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANYAND Fire Inspection
ALL CLAIMS FOR DAMAGES OF WHAT EVER NATURE, ARISING DIRECHNOR INDIRECTLY
Receipt #
Total Amt. Due
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 Landscape Insp.
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
Recording Fee
—A
Receipt ft
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION, THAI* 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- I his application is not a perinit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED CALL thillujilig 011icial or his/her Deputy. and Fees are paid, and
IN VIOLATION OF THE LA13OR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION wceipi is acknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18 27.
OFFICIAL ��iCINAIIURF DATE
SIGNATURE (OWNER 0 GEN DATE SIGNED (425) "-V
DATE
771-0220 ari rAsrD ny
ATTENTION EXT 1333
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 YELLCrN INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK-OWNE11 GOLD -ASSESSOR
09iO3 PRESS HARD -YOU ARE MAKING 4 COPIES
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MICROFILM
OIL TANK DECOMMISSIONING CERTIFICATE
TANKS BY DALLAS HAS DECOMMISSIONED THE OIL TANK
AT: — I * 7 0- 2 0 _- fa Ll I b nat I &1ma
IFCI UST CERTIFICATE NUMBER EXPIRATION DAI
DECOMMISSIONER'S SIGNATURE:
NAME PRINTED
APPROXIMATE AGE OF TANK.- -TANK SIZE.
LAST CONTENTS OF TANK: Q�_s SOIL CONTAMINATION 0
DECOMMISSIONING TYPE: REMOVAL -
FILL IN PLACE
RINSE AND CAP___L
DATE OF DECOMMISSIONING21-- - 1 - 09
THE WORK WAS DOME IN ACCORDANCE WITH LOCAL AND STATE REGULATIONS -
TANKS By DALLAS HAS MADE ALL MEANS TO LEAVE THE SITE AS CLOSE AS
POSSIBLE To ITS ORIGINAL CONDITION. TANKS BY DALLAS IS NOT LIABLE FOR
UNDERGROUND CONDITIONS AT THIS TIME OR ANY TIME IN THE FUTURE. ANY
AND ALL KNOWN UNDERGROUND CONDITIONS AND ANY POTENTIAL UNKNOWN
UNDERGROUND CONDITIONS HAVE BEEN PROPERLY CONVEYED TO I HE PERSON
AUTHORMUNG THE TANK WOfVvL THIS CERTIFICATE IS THE RESULT OF A BINDING
AGREEMENTICONTRACT PRODUCED PRIOR To COMMENCEMENT OF THE TANK
DECOMMISSIONING -
"THE IFCI CERTIFIED UST DECOMMISSIONER NOTED ABOVE IS
RESPONSIBLE FOR NOTIFYING THE PERSON AUTHORIZING THE
WORK OF A CONFIRMED PETROLEUM RELEASE LEAK OR SPILL. AS
THE RESPONSIBLE PARTY AUTHORIZING THE WORK, SAID PARTY
MAY HAVE RESPONSIBILITIES UNDER THE LAW TO REPORT
PETROLEUM RELEASE, LEAKS OR SPILLS TO THE APPROPRIATE
STATE OR FEDERAL AGENCIES.
TANKS BY DALLAS
1955140T" PL NE-
SEATTLE., WA 98155
206-365-0291/FAX 361-0992
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
Ell
cjr? OF q)�Notlt
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: - _�f � %Ik� FIRE DEPARTMENT DAT
_'&Mt 1 C_
ASE SIGN
ENGINEERING DIVISION DATE
PLE,ml! SIGN
PLANNING DIVISION DATE —
PLEASE SIGN
PROJECT � KP�-- ?U-�E 4- Cg�'�
V
SITE ADDRESS � 76
PERMIT #rf;�� — (06_6'� _ADB# DATE INSPECTED
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 release of
PERF ORMANCE BONDS and the granting of:
=L���GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
1 .
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
Copy of CORRECTION NOTICE given to owner/contractor. by inpector
1 .
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:fbnns:ocaprv1 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch .................
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
Rough -in ....................
Commercial Final ......
HEATING:
Gas Test ....................
Gas Piping .................
Equipment .................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST FLOOR FRAMING...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL P@" k
Qw9etjP*"* . ................
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