20040862.pdf1 DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMENAME OF BUSINESS
MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
ADDRESS
NAME
ADDRESS
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CITY
STATE LICENSE NUMBER
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PROPERTY TAX AcCGUN
11 NEW
1:1 ADDITION
11 REMODEL
1:1 REPAIR
11 DEMOLISH
0 GARAGE
CARPORT
(TYPE OF USE, BUSINEE
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ZIP
TELEPHONE
ZIP TELEPHONE
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EXPIRATION DATE
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PARCEL NO.
M RESIDENTIAL
'WCOMMERCIAL
1:1 MULTIFAMILY
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GRADING CYDS
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TANK
RETAINING WALL
ROCKERY
OR ACTIVITY) EXPLAIN:
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Lu NUMBER NUMBER OF
0 OF DWELLING
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0 STORIES UNITS
DESCRIBE WORK TO BE DONE
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PLUMBING/MECH
COMPLIANCE OR
CHANGE OF USE
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FIRE SPRINKLER
FIRE ALARM
CRITICAL
AREAS
NUMBER
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HEAT SOURCE I GLAZING %
PLAN CHECK
LOT SLOPE %
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. I 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
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
NOR LIMIT IN ANY WAY THE CIIYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
I HEREBY ACKNOWLEDGE THAT I HAVE READ T141S APPLICATION; THAT THE 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
WORKMEN'S -,COMPENSATION INSURANCE AND RCW 18.27.
�JNATURE E EN DATE SIGNED
PERMIT EXPIRES
USE PERMIT
ZONF.
NUMBER
JOB SUITE/APT#
ADDRESS '7c, Ci f? 2V_ 0 9�-r, .5 W
PLAT NAMEISUBDIVISION NO LOT NO.
LID NO.
LID FEE $
TESCP Approv0a
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW pernut Requited
0
Street Use Permit Req'd
EXISTING — PROPOSED
inspection Required
Sidewalk Required
13
13
REQUIRED DEDICATION� FT
Underground
Wiring required
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METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
0
YES NO 0
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE W
VARIANCE OR CU S RELINE WOAD9 INSPECTION I — BOND
REGT POSTED
LNO LS
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SEPA REVIEW SIG REA HEIGHT
COMPLETE , EXEMPT A LOWED PROPOSED ALLOWED PROPOSED
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EXP
LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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FLOT AREA PVA&INING REVIEWE IL
PARKING D y DATE
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REMARKS
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CHECKjn BY TYPE I OF CONSTRUCTION bccuPANT
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SPECIAL INSPECTION AREA OCCUPANT
IT it LOAD
REQUIRED [] YES
REMARKS
PROGRESS INSPECTIONS PER UBC 108 / IBC109 IRC109 FINAL INSPECTION REOID
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
FEE
Description
Cm
FEE
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State Surcharge
City Surcharge
Base Fee
CALL
FOR INSPECTION
(425
5
771-02
Plan Chk. Deposit A�5
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building 011icial or his/her Deputy: and Fees are paid, and
receipt is ac�povrledged in space provided.
FF ALS E DATE
ELEAS D BY ATE
ATTENTION E)ff 1333__�L
ITIS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/IBC110/iRC110.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK -OWNER GOLD -ASSESSOR
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MEMORANDUM
Date: 10/28/04
To: Debbie Karber, Accounting Assistant
From: Marie Harrison
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SUbject: REFUND
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Debbie, please prepare a refund check in the amount of $110.00. Please mail the check to
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Dwinell's Visual Systems, 7400 W Arrowhead, Kennewick, WA 99336. Please deduct $60.00
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out of the.plan check fund and $50.00 out of the building permit fund. I have enclosed a copy of
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our receipt #25102 for your records. Thank you.
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Sincerely,
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Development Services Division Director's Signature
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-a Community Services
City of Edmonds C,
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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 ..........
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FINAL APPROVAL FOR VN�
32:2���
OCCUPANCY ..................
The initials MTare Milton
Tholi'Ps011, a telliporary contract
ilispector for 1.110 city.
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