20040654 (2).pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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CITY ZfP TELEPHONE
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NAME
ADDRESS
CITY
NAME
ZIP I TELEPHONE
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FPERMIT EXPIRES
USE PERMIT
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NUMBER
JOB SUITEIAPT#
ADDRESS
PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE $
IESCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Requilod
straw use Permit Ract'd
EXISTING - PROPOSED inspection Required
Sidewalk Required
Underground
REQUIRED DEDICATION� IFT Wiring required
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
I I YES 11 NO 0
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TELEPHONE
STAfE LICENSE NUMI , 3ER
EXPIRATIO
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PROPERTY TAX ACCOUNT PARCEL NO.
20o 42 �06; S 02-30
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NEW
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RESIDENTIAL
PLUMBING/MECH
F1
ADDITION
COMMERCIAL
24c
COMPLIANCE OR
F-1 CHANGE OF USE
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REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING
CYDS
FENCE
El ( X. FT)
13
DEMOLISH
1:1
TANK
OTHER
EiGARAGE
CARPORT
13
RETAINING WALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
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(TYPE OF USE, BUSLqESS OR ACTIVITY) EXPLAIN
NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
STORIES UNITS o& I NUMBER
I I DESCRIBE'hORK TO BE DONE
HEAT SOURCE
GLAZING %
Ono
LOT SLOPE %
PLAN CHECK VESTED DATE
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
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF IHIS PERMIT SHALL Nor BE
a DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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.0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION'
I I EREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT IIIE INFORMATION
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-
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
WORKME��MPENSATION INSURANCE AND RCW 18.2T
SIGNAT WREN DATE I, NED
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
F: UT
BY
DATE
DATE
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VARIANCE OR CU SHORELINE OR AOB# I INSPECTION BOND
k REO'D POSTED
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SEPA REVIEW SIGN AREA HEIGHT
COMPLETE E? i4PT ALLOWED
�E PROPOSED OWED PROPOSED
EXP
LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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PARKING LOT AREA PPP QL
REO'D fIDED )NING VIEW D Y DAT;
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REMARKS
CHECKED BY TYPE OF CONSTRUCTION E OCCUPANT
GROUP
_�FECIAL INSPECTION AREA OCCUPANT
YES
REQUIRED LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108/IBC109/IRC109 FINALINSPECTION RE9D
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
CALL
FOR INSPECTION
(425)
771-0220
FEE Description FEE
State Surcharge
.fsr, Z City Surcharge
Base Fee
Plan Chk. Deposit
Receipt N
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by The
Building ollicial or tusitier Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
F�19IALS S,IQVATURE DAT E
/ , ��// —VIZ-el
�X&ED fW_ DATE
AT*NTION I EXT 1333
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE ANDAPPROVALOR A CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/1BC110/lRC110.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
ORIGINAL -FILE YELLOW
PiNK-OWNER GOLD.
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JUL-20-2004 12:43 P.03/03
RECEIVED
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SITE PLAN
ADDRESS
22315 Hwy 99 #.V)C�
Edmands,WA
98026
FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDfNATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLFASE SIGN
ENGINEERING DIVISION DATE
P"LFASE SIGN
44 i�& PLANNING DIVISION DATE_1�/6/( )
PLEASC SIGN
PROJECT
SITE ADDRESS —
PERMIT# �qaq- o65 ADB# DATEINSPECTED
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
PERFORMANCE BONDS and the granting of:
GRAN T FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE given to owner/contractor by inpector
I
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signattire
1:temp:b1dg:fonns:ocaprv1 3/25/04
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