20050113.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER 14AMEiNAMEPF BUSINESS
MAILINGADDRESS
CITY ZIP TELEPHONE
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NAME
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ADDRESS
CITY ZIP
STATE LICENSE NUMBER
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olp I I PERMIT EXPIRES
PERMIT
NUMBER
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PLAT NAMEISUBDIVISION NO.
I LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved 13
13
RW Perint Requited
Street Use Porrill equire [3
EXISTING PROPOSED
Inspection Required 13
Soeowatk Requited 13
REQUIRED DEDICATION FT
Undotgiound C3
E3
Wand required
METER SIZE
LINE SIZE
NO, OF FIXTURES
PRV REQUIRED
YES13 NO13
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY
DATE
FIRE REVIEWED BY
DATE
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TELEPHONE
VARIANCE OR CU
SHORELINE OR AD
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INSPECTION
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ALLOWED I PROPOSED ,
1.39" 17 .40
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ALLOWED PROPOSED
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NEW
REMODEL
REPAIR
DEMOLISH
RESIDENTIAL
200'COMMERCIAL
MIXED USE
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GRADING
CYDS
TANK
1:1 PLUMBING it MECH
COMPLIANCE OR
M CHANGE OF USE
2�_'S 5IG N
FENCE
1:1 ( X FT.)
OTHER
1:1
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS IFT.)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT LIRSIDE REAR
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PARKING
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PLANNING REVIEWED BY DATE
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REMARKS —1
Tollii �,jj, log 17.4 4- 9 3 ;rZ&
GARAGE
CARPORT
RETAINING WALL
ROCKERY
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FIRESPRINKLER
FIRE ALARM
(TYPE
OF USE. BUSIIN�S
OR ACTIVITY)
EXPLAIN.
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OCCUPANT
GROUP
6
NUMBER
NUMBER OF
OF DWELLING SPECIAL INSPECTION C
STORIES UNITS REQUIRED 1:3 YES
DESCRIBE WORK TO BE DONE
REMARKS
GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description
VE STEDDATE Plan Check
HEAT SOURCE LOT SLOPEO/c Building Permit
PLAN CHECK NO: I Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION.
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5) Review
PERMIT LIMIT. SEE ECDC 119-00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS Fire Review
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSLIANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE LandscapeInsp.
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee
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
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL
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 FOR INSPECTION
WORKMEN'S COMPENSATI��ANCE AND RCW 18:27.
- SIGNATURE (0 NER ORjT S IED (425)
4r
DATrE
-0220
x 771
OATTE Of I Of4 EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110.
OCCUPANT
LOAD
FEE Description FEE
State Surcharge
City Surcharge
U
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
1 Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
D IBY I (DAT
ORIGINAL -FIK YELLOW -INSPECTI!
PINK - C KER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING, DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASE SIGN
ENGINEERING. DIVISION. DATE -
PLEASE SIGN
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PLANNING DIVISION DATE
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PLEAS(PdN
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PROJECT
SITE ADDRESS ��A AvE
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PERMIT # 0 ADB# DATE INSPECTED
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DESCRIPTION OF WORK TO BE INSPECTED
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A field inspection was conducted to determine compliance with -.approved plans. Final approval
65
denotes that there are no objections from the above signed Department to the release of
0
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 owndr/contractor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
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0 Co y of CORRECTION NOTICE given to owner/contractor by inpector.
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2.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT. APPROVAL
Date. Signature
1Jemp:b1dg:fbrtns:ocaprv1 3/25/04