20050010.pdfDATE RECEIVE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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Plan Check State Surcharge
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HEAT SOURCE GLAZING % LOT SLOPE % Building Permit City Surcharge
PLAN CHECK NO: VESTED DATE Plumbing Base Fee —
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: 180DAYS
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PERMIT LIMIr I YEAR - PROVIDED WORK IS STARTED WITHIN 160 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
M 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 Landscapeinsp. Total Amt. Due
!3 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.'
Recording Fee Bipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT 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- CALL This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/her Deputy: and Fees arc 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 CO IC SIONAT DATE
.,��N,,SATION INSURANCE AND RCW 18.27. --- I & du
Sic; Ttr (0 9f OR AG5N'0 DATE SIGNED (425)
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AT E TION EXT 1333 1W, A --hin
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 14;WC24
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL - FILE YELLOW - I SPE/TOR
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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FINAL PROJECT APPROVAL FORM
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MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
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FROM: FIRE DEPARTMENT DATE 2_6 0 Is
PLEASESIGN
ENGINEERING DIVISION DATE
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PLANNING DIVISION DATE
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PROJECT iA/bL
SITE -ADDRESS 33 (21, tA_1
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PERMIT # 00 10 ADB# DATEINSPECTED
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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 PROJECT APPROVALWITH CONDITIONS NOTED
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El 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
1:temp:b1dg:forn1s:ocaprv1 3/25/04
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RECORD OF INSPECTIONS