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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION. PERMIT APPLICATION
OWNER NAME/NAME OF Bum
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NAME
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PERMIT EXPIRES
USE PERMIT
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ADDRESS
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PLAT NAME/SUBDIVISION NO.
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LID NO.
LID FEE $
PUBLIC RIGIR OF WAY PER OFFICIAL STREET MAP
7ESCP Approved
RW Permit Required
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Street Use Permit Roq'd
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EXISTING PROPOSED
Inspection Required
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sidewalk Required
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REQUIRE[) DEDICATION- Fr
Underground
Wiring required
METER SIZE
LINE SIZE
OF FIXTURES
PRV REQUIRED
YES13 NO 13
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REMARKS
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OWNER/CO'4114ACIOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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FIRE REVIEWED 13Y
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ALLOWED PROPOSED
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REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (FT)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LIRSIDE REAR
ADDITION
COMMERCIAL
COMPLIANCE OR
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CHANGE OF USE
PARKING
LOT AREA
PLAN NINO REVIEWED BY DATE
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GRADING FENCE
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DEMOLISH TANK OTHER
RETAINING WALL FIRE SPRINKLER
GARAGE
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NUMBER 4UMBER OF
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DWELLING AREAS
STORIES UNITS NUMBER
DESCRIBE WORK TO BE DONE
SPECIAL INSPECTION
REQUIRED [] YES
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REMARKS
PROGRESS INSPECTIONS PER UBC I 08/FINAL INSPECTION REOV
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VALUATI.ION
Description
FEE Description FEE
Plan Check
State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
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Building Permit
City Surcharge
PLAN CHECI�r, 5 e:9 VESTED DATE
Plumbing
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
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Engr. Review
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W PERMIT APPLICATION: 180 DAYS
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
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IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
ITS OFFICIALS, EMPLOYEES, AND ANY AND
M EDMONDS, WASHINGTON, AGENTS FROM
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 HE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landscapelnsp.
Total Amt. Due
01 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee
Receipt #
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'
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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 are paid. and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt Is acknowledged in space provided.
WO��'S COMPENSATION INSURANCE AND RCW 18.27.
URE DATE
SIGNAjUR OWNER 011�1� ATE SIGNED
(425)
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771-0220
L SED DATE
ATTENTION
EXT 1333
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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 A CERTIFI-
ORIGINAL -FILE - YELLOW INSPE on
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
PINK -OWNER GOLD-ASSEIR
04102 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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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 (41
PLEASESIGN
ENGINEERING DIVISION DATE
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PLEASE SIGN
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PLANNING DIVISION DATE
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PROJECT PA_ y d /V
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DESCRIPTION OF..WORK TO BE INSPECTED ER -A
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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 frorn_ 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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El Copy of CONDITIONS given, to owner/contractor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
Copy of CORRECTION NOTICE given to ow.ner/contractor by inpector
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:fon-ns:ocaPrv1 3/25/04