20050440 (2).pdfDATE RECEIVED 5`24
PERMIT EXPIRES
RMIT
CITY OF EDMONDS Nu BER �'�" ,e/
CONSTRUCTION PERMIT APPLICATION
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CITY ZIP TELEPHONE
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NAME
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ZIP .TELEPHONE
JOB SUITEIAPT#
ADDRESS '5141,1141 S�
PLAT NAMEISUBDIVISION NO. `LOT NO. LID NO
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved ❑
RW Permit Requited ❑
Street use Permit Requited ❑
EXISTING PROPOSED _ _ Ins{wctMn Requited ❑
Sidewalk Required ❑
REQUIRED DEDICATIONFT undetgrouM ❑
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METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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REMARKS W
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE _
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ADDRESS
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CITY ZIP TELEPHONE Ir
STATE LICENSE NUMBEREXPIRATION DA E CHECKED BY VARIANCE OR CU SHORELINE OR ADB# INSPECTION SERA
5�/�/ ��� ' 0� REQ'D COMPLETED EXEMPTA YES D NO
PROPERTY TA CCOUNT PARCEL NO. � CA# ZONE SIGN AREA HEIGHT
/7O '7 21 2 000SV SVC`
WAIVER Q ALLOWED PROPOSED ALLOWED PROPOSED
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❑ NEW ❑ RESIDENTIAL �pLUMBING / MECH LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR . FRONT UR SIDE PEAR O
COMMERCIAL COMPLIANCE OR z
❑ ADDITION ❑ CHANGE OF USE _
/E3MIXED USE PARKING LOT AREA PLANNING REVIEWED BY DATE g I
E]REMODEL ❑ MULTIFAMILY ❑ SIGN REO'D PROVIDED a
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GRADING
❑ REPAIR 11CYDS ❑ ENCE X FT.) REMARKS
❑ DEMOLISH ❑ TANK ❑ OTHER
GARAGE ❑ CARPORT 13RO ROCKERY NING WALL ElFIREALARM FIRE LER
TYPED SE, BUSINESS OR ACTIVITY) EXPLAIN:
OTRUCTION
OCCUPANTTYPE
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NUMBER NUMBER OF ^ A
OF DWELLINGI �SPECIAL INSPECTION CONSULTANT OCCUPANT
STORIES UNITS ,I/4 LOAD
REQUIRED O YES
DESCRIBE WORK TO BE DONE
1 • , `br*� - GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description FEE Description. FEE
Plan Check Slate Surcharge
HEAT SOURCE LOT SLOPE% VESTED DATE
Building Permit City Surcharge
PLAN CHECK NO: Plumbing Base Fee �S
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO Mechanical Z�
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
E DONMAIN (CURBS, SIDEWALKS, DRIVEWAYSt MARQUEES, ETC.) WILL REQUIRE Grading
SEPARATE PERMISSION,
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
L 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 Plan Chk. Deposit
IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
E EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
1 ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
C 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 Landscape Insp. Total Amt. Due (r�O
= NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.• C L
Recording Fee 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 This application is not a perinit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL Building Official or his/her Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED FOR INSPECTION receipt is acknowledged in space provided.
IN VIOLA 10 OF THE L CODE OF THE STATE OF WASHINGTON RELATING TO
WORK S OMP NS Ln
I URANCE AND RCW 18:27. OFFICIALS SIGNATURE ATE
?SIGNRE W A N : DATE SIGNED (425)l771 -0220 REL DATE
NTION EXT. 1333 4 C -
LAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL -FILE YELLOW -INSPE OROF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 I IRC110. PINK -OWNER • GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT O TOI - -LDING DIVISION
FROM: FIRE DEPARTMENT DATE
PERMIT
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ENGINEERING DIVISION DATE
PLEASr SIGN
PLANNING DIVISION DATE
..: PLEASE SIGN _ -
PROJECT A^1+7�6;)
SITE ADDRESS 5 AJ S7
PERMIT # �'" �1 0 ADB# DATE INSPECTED �3 0
DESCRIPTION OF WORK TO BE INSPECTED
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
ooj GRANT FINALPROJECT 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
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