20050118.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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STATE LICENSE NUMBER EXPIRATION DATE
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-IJI PROPERTY TAX ACCOUNT PARC.ft NO, 1, ;
NEW
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RESIDENTIAL
PLUMBING / MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
MIXED USE
REMODEL
F-1
MULTIFAMILY
SIGN
REPAIR
GRADING
CYDS
FENCE
( X FT.)
DEMOLISH
TANK
OTHER
GARAGE
RETAINING WALL
FIRE SPRINKLER
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CARPORT
ROCKERY
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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DESCRIBE WORK TO BE DONE
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PERMIT EXPIRES
PERMIT
NUMBER
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SUITE�APTP
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PLAT NAME /SUBDIVISION NO.
LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Appru�ed
RV.Pernir Required
Street use Peinia Required
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EXISTING PROPOSED
Inspoction Required
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REQUIRED DEDICATION FT
Undercriound
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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 CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY
FIRE REVIEWED BY
VARIANCE OR CU
WAIVER C&N��
STUDY 13
LOT COVERAGE
ALLOWED PROPOSED
DATE
DATE
SHORELINE OR AD89 INSPECTION SEPA
I #_ I REO'D COMPLETED EXEMPT
to .. ('9 2_0 N YES 0 NO 1 1___,>4
ZONE SIGN AREA HEIGHT
> ALLMED PROPOSED ALLO�VED PROPOSED
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REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.)
FRONT SIDE REAR FRONT L/R SIDE REAR
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PARKING LOT AREA I PLANNING REVIEWED BY DAT&.�W 0.
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OCCUPANT
GROUP
SPECIAL INSPECTIO14 CONSULTANT OCCUPANT
REQUIRED 13 YES I I LOAD I
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GEOTEC� REPORT
BY
STRUCTURAL DESIGN
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VALUATION
$ (9111169
Description
Plan Check
HEAT SOURCE
LOT SLOPE%
VESTED DATE
Building Permit
PLAN CHECK NO:
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
Grading
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Revie
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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PERMIT LIMIT: SEE ECDC 19.00,005(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
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EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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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
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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
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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 THI� STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S COMPEN_aAj1Qj_jNSURANCE A)IO RCW 18:27.
ORAGEN
FEE
Description
FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due if �Iqe'
Receipt #
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APPLICATION AP �ROV,
This application is riot apernia until Signed by the
Building official or his/her Deputy and Fees are paid and
feceipt isacknowltidged in space provided
OFFICIALS SIGNATURE I DATE
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RELEASED BY DATE
EXT. 1333
ATTENTION/`�
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL F IL li; YFA' L07V - TISPEIC VOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 I IRC110- PINK - OVVNER`--'6OLD - ASSESSOR
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
DATE SIGNED
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FINP-,,, PROJECT APPROVAL bjRM
TO:
DATE: ��)As oc
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASESIGN
ENGINEERING DIVISION DATE
PLEASESIGN
PLANNING DIVISION DATE
P IXASRSIGN
PROJECT Ki�,,., Shreek SYne-C Q_"4
SITEADDRESS-
PERMIT # ',;)00-15- 01 I!F� ADB# N
& DATE INSPECTED /12��
DESCRIPTION OF WORK TO BE INSPECTED C>C(
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
0 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
1:teniP:b1dg:f6rms:ocaprv1 3/25/04
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RECORD OF INSPECTIONS
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� INSPECTOR DATE APPROVED
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' SETBACKS —.----.—
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. FOUNDATION:
� Footing ------..
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� Pier/Porch .................
Retaining Wall ...........
/ Slab Insulation ..........
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! PLUMBING:
^ Underground .............
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. Rough -In ...................
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� Commercial Final --
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� HEATING:
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� Gas Piping ---.--
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Equipment ----.—
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� Commercial Final .......
� EXTERIOR SHEATHING
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INSULATION ------
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Floor Insulation .........
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Wall Insulation ...........
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` Ceiling Insulation .......
SHsETBOCKNAIUNG —
SPECIAL INSPECTION —
MISCELLANEOUS ..........
� FINAL APPROVAL FOR
OCCUPANCY ------
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