20050001.pdfFDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
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NAME ICBL#
ADDRESS
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY
PROPERTY TAX
NEW
RESIDENTIAL
El PLUMBING/MECH,
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
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MULTIFAMILY
SIGN
REPAIR
GRADING
CYOS
FENCE
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El DEMOLISH
TANK
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EiGARAGE
RETAINING WALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIV" EXPLAIN:
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NUMBER
NUMBER OF
CRITICAL
OF
DWELLING
AREAS
STORIES
UNITS
NUMBER
DESCRIBE WORK TO BE DONE
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HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHECK NO: VESTED DATE
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PERMIT EXPIRES ;;�Z�1-2_
USE PERMIT
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PLAT NAMEISUBDIVISION NO.
LOT NO.
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LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
IESCP Approved
RW Permit Required
13
Street use Permit Heri'd
E3
EXISTING - PROPOSED
inspection Required
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Sidewalk Hequirad
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REQUIRED DEDICATION- FT
Underground
Wiring required
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METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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FIRE REVIEWED BY
DATE
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INSPECTION
BOND
REO'D
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POSTED
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OYES ONO
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SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP ,
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LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LJRSIDE REAR
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PARKING
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LOT AREA
PLANNING REVIEWED BY DATE
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RFQ'D I PROVIDED
REMARKS
CHECKED BY ITYPE OF CONSTRUCTION CODF,_ OCCUPAtg
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GROUP/j
SPECIAL INSPEC N AR A OCCUPANT
REQUIRED YES LOAD
YES
REMARKS
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PROGRESS INSPECTIONS PER UBC I 08/FINAL INSPECTION REI
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
FEE Description
State Surcharge
City Surcharge
Base Fee
FEE
THIS PERMIT AUTHORIZES ONLyfTHE WORK NOTED. THIS PERMIT COVERS WORK TO
I= BE DONE ON PRIVATE PROPERTY O`NLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURDS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SrPARATIE PERMISSION. Engr. Review
PERMIT'APPLICATION: ISO DAYS
W I
IL PERMIT LIMIT: I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) '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
2 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 13E X71
DEEMED 70 MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapelnsp. Total Amt. Due
01 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
Recording Fee Receipt # a�L --f=
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE'INFORMATION
GIVEN IS CORRECT. AND THAT I AM THE OWNER. OR THE DULY AUTHORIZED AGENT OF APPLICATION APPROVAL
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Olficial or his/her Deputy: and Fees are paid, and
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 10.27.
OF?FV SIGN/ , U/E DATE
SIGNATURE (OWNER OR/GE�A DATE SIGNED (425)
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771-022 RELEASED BY
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 YELLOW -INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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MEMO TO: P I ERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
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00o FLEA F SIGN
ENGINEERING DIVISION DATE
PLEASE SIGN
PLANNING DIVISION DATE
PLEASESIGN
PROJEcT_j2d'-/-L'd* L�)
SITE ADDRESS
PERMIT# L)Q_LADB# DATEINSPECTED
D . ESCRIPTION OF WORK TO BE INSPECTED Ll,.. W5 47
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:
GRANT FINAL PROJECT APPROVAL -
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
El Copy of CONDITIONS given to owner/contractor by. inspector
FAILED FINAL INSPECTION OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
I temp:bldg: forms: ocaprvl 3/25/04
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