20050412.pdfDATE RECEIVE�,
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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NAME
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NAME
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY
PROPERTY TAX ACCOUNT PARCEL NO.
009,39 9 00000 200
NEW
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DESCRIBE WORK TO BE DONE
PERMIT EXPIRES 1 =16
PERMIT
NUMBER
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SUITE/APT$f
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO�
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
71 Approved
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RW Permit Required
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PROPOSED
Street use Permit Required
Inspection Required
Sidewalk Required 141�
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METER SIZE
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NO. OF FIXTURES
PRV REQUIRED
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY
FIRE REVIEWED BY
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REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
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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
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Grading
Engr. Review
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
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESSORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORD114ANCE
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Fire Review
Fire Inspection
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Recording Fee
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
'ORMAT'ON
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-
Mp Y 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 COM
_f5pATION INSI��ANC4ND RCW 18:2 DATE SIGNED
GNAT OR 7GE (425)
771-0220
FEE Description
State Surcharge
city surcharge
Base Fee.
IF 7�_� — t", - I
AtfENTION 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 f IBC110 / IRC110.
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FEE
Plan Chk. Deposit (A? b- CC-)
Receipt #
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Total Amt. Due
Receipt #
PLICATION APPROVAL
This application is not a permit until signed by the
Building official or hisihor Deputy! and Fees are paid, and
receipt is acknowledged in space provided,
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERA41T COORDINATOR, BUILDING. DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASE SIGN
ENGINEERING DIVISION DATE 7//
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DESCRIPTION OF WORK TO BE INSPECTED (n (7 J4'
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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
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PERFORMANCE BONDS and the granting of:
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RE-INSPECTED,OUTSTANDING ISSUES - GRANT FINAL PROJECTAPPROVAL
Date Signature
I:teiiip:I)I(lg:l*oriiis:oc.ir)rvI 3/25/04
F1 I NAL PROJECT APPROVAL FORM
DESCRIPTION OF WORK TO BE INSPECTED
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A field inspection Was conducted to determine. compliance with a proved plans. Final approval
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:teinp:b1dg:f'omis:ocaprv1 3/25/04-