20050517.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME1NAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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C I I PERMIT EXPIRES 42
PERMIT
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NUMBER
JOB SUITE/APT#
ADDRESS � y3l,!�
PLAT NAMEISUBDIVISION NO.
LOT NO
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LID FEE S
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCPApproved
RW Permit Requited
EXISTING ____ PROPOSED
Strem Use Permit Required
Inspection Required
Striewalo. Requited
REQUIRED DEDICATION FT
Undelgiound
Wiring rriq�ifed
METER SIZE
SIZE
NO. OF FIXTURES
PRV REQUIRED
7LINE
YES 13 NO 1:1
REMARKS
OWN ERIC ONTRACTO R RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
BY
FIRE REVIEWED BY
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DATE
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VARIANCE OR CU SHORELINE ORADE11 I INSPEC SEPA
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DATE CHECKED BY RI _ D COMPLETED I EXEMPT
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CAN
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SIGN AREA
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PROPERTY TAX ACCOUNT PARCEL NO.
WAIVER�
ALLOWED PROPOSED
ALLOWED PROPOSED
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PLUMBING / MECH
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REQUIRED SETBACKS (FT.)
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PROPOSED SETBACKS (FT.)
FRONT URSIDE REAR
ADDITION
COMMERCIAL
COMPLIANCE OR
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MIXED USE
CHANGE OF USE
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REMODEL
PARKING
REQ*D PROVIDED
LOTAREA
PLANNING REVIEWED BY DATE
MULTIFAMILY
SIGN
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REPAIR
GRADING
CYDS
FENCE
( x FT.)
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REMARKS
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TANK
OTHER
1:1 GARAGE
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RETAINING WALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIREALARM
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLIN;
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NUMBER
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NUMBER OF
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STORIES
UNITS
REQUIRED 13YES
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LOAD
DESCRIBE WORK TO BE DONE
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REMARKS
GEOTECH REPORT
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STRUCTURAL DESIGN
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VALUATION
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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 ORDINANCE
NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
Fire Review
Fire Inspection
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IRecording Fee
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN 15 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- 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 COMPENSAT��NSURANCE AND RCW 18:27.
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SIGNATURE (OW _jDDATE SIGNED
6 1.40 'y 771-0220
FEE Description
State Surcharge
City Surcharge
Base Fee
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Receipt # A ab �LA
APPLICATION APPROVAL
This application is not it pernnit until signed by the
Building official or his/her Deputy: and Fees are paid. and
roceirfN acknowledged in space provided
ATTEWf6N 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 / IBC110 I IRC110.
1101114 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTO
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FINAL PROJECT APPROVAL FORM
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MEMOTO: PERMIT. COORDINATOR, BUILDING DIVISION
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DESCRIPTION OF WORK TO BE INSPECTED
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denotes that there are no objections from. the above signed Department to th e re lease
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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
copy of CONDITIONS given to owner/contr actor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
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Copy of CORRECTION NOTICE gi . ven to. owner/contracto by i npector
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RE -INSPECTED OUTSTANDING ISSUE, S GRANT FINAL PROJECT APPROVAL...
Date Signature
I:temp:b Idg: forms: ocaprvl 3/25/04.