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[PERMIT EXPIRES
USE PERMIT
. CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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ADDRESS
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OWNER NAME/NAME OF BUSINESS
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PLAT NAME/SUDDIVISION NO.
LOT NO.
LID NO.
LID FEE $
MAILING ADDRESS
76 0
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING - PROPOSED
REQUIRED DEDICATION- FT
TESCP Appr'ov0d[3
RW Permit Required Q
Street Use permit Roq'd 13
inspection Required 13
Sidewalk Required 13
underground
Wiring required 13
CITY ZIP
144/25�-772-
TELEPHONE
NAME METER SIZE LINE SIZE I NO. OF FIXTURES PRV REQUIRED a
YES E3 NO 13 K-
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE CUECKED BY
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J I PROPERTY TAX ACCOUNT PARCEL NO.
ENGINEEF31NG RA\
FIRE REVIEWED 87
Rr-Mr DATE
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION BOND
REO'D POSTED
OYES ONO IS
SEPA REVIEW SIGN AREA HEIGHT
L;UMFLhIE , EXEMPT ALLOWE D PROPOSED ALLOWED PROPOSED
EXP I I I
NEW AM. RESIDENTIAL PLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS tri.)
I ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR 11
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FIRE ALARM
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REMARKS
(TY E OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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NUMBER
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LOAD
7SE8CRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS
PER UBC 1108/171NAL INSPECTION REO'D
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE GLA ZING % LOT SLOPE %
Building Permit
City Surcharge
rLAN CHECK NO: VESTED DATE
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
2
Engr. Review
Ix PERMIT APPLICATION: 180 DAYS
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PERMIT LIMIT' I YEAR - PROVIDED WORK IS 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
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
X FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
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Total Amt. Due
9 DEEMED TO MODIFY WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
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Recording Fee
Rec
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
REBY
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VAL
APPLICATION APPROVAL
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IS CORRECT, AND THAT I AM THE OWNER, On THE DULY AUTHORIZED, AGENT OF
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THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
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CALL
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This application is not a permit until signed by the
TION; ANO IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
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Building 011icial or his/her Deputy: and Foos are paid, and
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IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
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FOR INSPECTION receipt Is acknowledged In space provided.
ORKMEN'S COMPENSATION��URANCE AND RCW 118.27.
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SIGNATURE (OWNERfR N DATE SIGNED
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14.0001
771-0220
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ATTENTION
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR )yZf�,11TIFl-
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ORIGINAL -FILE YELLOW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER GOLD -ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
DEPARTMENT DATE
FROM: FIRE
PLUASF SIGN
ENGINEERING DIVISIONDATE-
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PLEASHSIGN
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PLANNING DIVISION DATE
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PERM IT ADB# DATE INSPECTED
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DESCRIPTION OF WORK TO BE INSPECTED /1-L-e
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A field, inspection was conducted to determine compliance with approved plans. Final approval
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denotes that there are no objections from the. above signed Department to the release of
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PERFORMANCE BONDS and the granting of:
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GRANT FINAL PROJECT APPROVAL
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GRANT PROJECT. APPROVAL WITH.CONDITIONS NOTED
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Copy of CONDITIONS given to owner/contractor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
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0 Copy of CORRECTION NOTICE, given to owner/contractor by inpector
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RE -INSPECTED OUTSTANDING, ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1Jeinp:b1dg:fbmis:ocaprv1 3/25/04