20050312.pdfFDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
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CITY
NAME
NAME
ZIP TELEPHONE
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PERMIT
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PERMIT EXPIRES
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ADDRESS
SUITE'dPT1$
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PLAT NAMEISUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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RW Permit Required
Street Use Permit Required
13
EXISTING PROPOSED
Inspection Required
[3
Sidewalk Required
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REQUIRED DEDICATION FT
underground
13
WmnU required
METER SIZE
LINE SIZE
OF FIXTURES
PRV REQUIRED
YESM NO13
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY DATE
ADDRESS
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CITY ZIP
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INSPECTION
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STATE LICENSE NI IM EXPIRATION DATE
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STUDY 13
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ALLOWED I PROPOSED
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PROPERTY TAX ACCOUNT PARCEL NO.
NEW RESIDENTIAL PLUMBING . MECH
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Do CHANGE OF USE
E] MIXED USE
REMODEL MULTIFAMILY E] SIGN
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT URSIDE REAR CD
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PARKING
REQ'D PRO IDED
LOT AREA I
PLANNING REVIEWED BY DATE4/
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GRADING FENCE
REPAIR CYDS ( x FT.)
DEMOLISH TANK OTHER
GARAGE o RETAINING WALL o FIRE SPRINKLER
CARPORT ROCKERY FIREALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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OF CONSTRUCTIOK
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OCCUPAN
GROUP
NUMBER
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NUMBER OF
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UNITS IVIk
SPECIAL INSPECTION
REQUIRE[) DYES
CONSULTANT
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
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GEOTECH REPORT
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VALUATION
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Description
FEE
Description
FEE
Plan Check
State Surcharge
416261
HEAT SOURCE
LOT SLOPE%
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ESTEDID TE
Building Permit
City Surcharge
—
PLAN CHECK NO:
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
Grading
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC,) WILL REQUIRE
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SEPARATE PERMISSION.
Engr. Roviow
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr Inspection
U) Firo Roviow
In OAPPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS "21- Plan Chk, Doposit
3 ALL
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.j IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fro Inspection Recoipt
ALL CLAIMS FOR DAMAGES OF W14ATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
X FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE Or THIS PERMIT SHALL NOT BE
C' DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE t-andscape Insp Total Anit Duo 621)
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION'
Recording Fou Roceipt I$ 4,Lxv
I HEREBY ACKNOWLEDGE T14AT .1 HAVE READ THIS APPLICATION; THAT THE INFORMATION APP71MCATION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUT14ORIZED AGENT OF Thisaiwlwallon is 'lot -1 P41111111 ""III Si(Ilud bY III0
THE OWNER. I AGREE TO COMPLY WIT14 CITY AND STATE LAWS REGULATING CONS IRUC- CALL FIL0,11m) offi(I'll of 11101111 Doputyarld I'll Isalo pald'irld
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL HE EMPLOYED . tiv,olpt
IN VIOLATION Of THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S COMPENSATION INSURANCE AND RCW 1111, Of FICIAI S SIGNAIL041 0ATE
SIGNATURE (OWNER OWA�GENT): TE IGNED (425)
LN *5 771-0220 14111
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ATTENTION 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- RIGINAI F I Y[ 1A OW INSP( C Tot?
PINK o 'it GOLD AS S17 SSO I J
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 f IBC110 III IRC110 ) !j
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FINAL PROJECT APPROVAL FORM
To:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE�—
C-PLEASE SIGN
ENGINEERING DIVISION DATE
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PLANNING DIVISION DATE
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PLEASE SIGN
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SITE ADDRESS. [90 16�1�A '00�v
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PERMIT #200 (2, DATEINSPECTED �7
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DESCRIPTION OF WORK TO BE INSPECTED t
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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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0, 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-fNSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:te111p:b1dg:fbrnis:ocaprv1 3/25/04