20050542.pdf.11 1 q -
DATE RECEIVED
[PERMIT EXPIRES
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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NUMB I ER
JOB SUITE/APT#
ADDRESS
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OWNER NAMEINAME OF BUSINESS
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PLAT NAMEISUBDIVI SION NO,
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LID NO.
LID FEE $
MAILING ADDRESS
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING PROPOSED
REQUIRED DEDICATION FT
TESCPApproved
RW Permit Required
Street Use Permit Require I d
Inspection Requited
Sidewalk Required
Underground
Wiring required
CITY ZIP
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TELEPHONE
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NAME
METER SIZE
LINE SIZE
NO. OF FIXTURES
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NAME
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ENGINEERING REVIEWED BY DATE
ADDRESS
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— FIRE REVIEWED BY DATE W
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STATE LICENSE NUMBER EXPIRATION DATE — Y VARIANCE OR CU �HORELINEORADBN INSPECTIO SE7A
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PROPOSED SETBACKS (FT.)
FRONT URSIDE REAR
COMPLIANCE OR
CHANGE OF USE
PARKING
REQ'D PROVIDED
LOTAREA
PLANNING REVIEWED By DATE
SIGN
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OTHER
FIRE SPRINKLER
FIREALARM
TYPE OF CONSTRUCTION CODE OCCUPANT
GROUP
NUMBER NUMBER OF
OF I DWELLING L A SPECIAL INSPECTION CONSULTANT
STORIES _ - -1 UNITS REQUIRED DYES
DESCRIBE WORK TO BE DONE
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Description
A141), PrA)AL-
Plan Check
HEATSOURCE
LOTSLOPE%
VESTED DATE
Building Permit
PLAN CHECK NO:
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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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Recording Be
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
FEE
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THE OWNER. I AGREE TO COMPLY WITH CI AND STATE LAWS REGULATING CONSTRUC- CALL
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TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
To
IN VIOLATION OF THE LABOR C9jA_QF THE STATE.OF WASHINGTON ELATINJ FOR INSPECTION
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WORKMEN'S COMPENSAI��NqE AND RCV6 "-I.
WN VENTV DATE SIGNED (425)
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7- 7 -0220
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ATTENTibN 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.
OCCUPANT
LOAD
Description
State Surcharge
City Surcharge
Base Fee
71�r,ffhmflh
Plan Chk. Deposit
14
FEE
Rece pt
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not it permit until signed by the
Building Official or his/hot Deputy and Fees are paicl and
receipt is acknowledged in space provided
FICIA 7SIGN W OAT F
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FINAL PROJECT APPROVAL FORM
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MEMO TO. PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLrASESIGN
ENGINEERING DIVISION DATE
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PLANNING DIVISION DATE
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PERMIT # ADB# DATE INSPECTED
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-DESCRIPTION OF WORK TO BE INSPECTED
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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,
PERFORMANCE BONDS and the granting of
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A GRANT FINAL PROJECT APPROVAL
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE given to owner/contractor by inpector
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANi,FINAL PROJECT APPROVAL
Date Signattire
1:tetnp:b1dg:fornii:ocapr'v1 3/25/04