20050584.pdf�_TDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
NAME
ZIP TELEPHONE
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NAME BL#
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STATE LICENSE N EXPIRATION DATE
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PROPERTY TAX ACGQUNT PARCEL NO.
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NEW
RESIDENTIAL
ADDITION
COMMERCIAL
MIXED USE
REMODEL
MULTIFAMILY
RE
GRADING CYDS
DEMOLISH
TANK
GARAGE
RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPJAIN
PERMIT EXPIRES 1�fff,
PERMIT
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NUMBER
JOB ITE/APT#
ADDRESS
PLAT NAME/SU B DIVISION NO LOT NO. LID NO,
I LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved
RW Permit Required
Street use Permit Required
EXISTING IROP Inspection Required
PSED T rT,,- D Sidewalk Required
REQ61RED DEDICAT& FT Underground
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METER SIZE I:INE _IiE NO. OF FIXTURES PRV REQUIRED
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CA
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REMARKS OlKli-jil,
OWNERJCONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
WAILK 19111- 1 I-,K ItJ 5h KhNIIL)VED OR
HOSE BIB WITH AVB INSTALLED
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ENGINEERING#EVIk,V4fE1LyKLIST ON BACK OF J053;LEARD
FOR INSPECTION REQUIREMENTS
FIRE REVIEWED BY DATE
VARIANCE OR CU SHORELINE ORADBI I INSPECTION SEPA
REO'D COMPLETED EXEMPT
13YES C
CAN qq7 ZONE SIGN AREA HEIGHT
WAIvL:ii Li ALLOWED , PROPOSED ALL,OWED I PROPOSED
STUDY K 01 1
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
E] PLUMBING/MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT URSIDE REAR
COMPLIANCE OR z
CHANGE OF USE
PARKING LOTAREA PLANNING REVIEWED BY DATE
SIGN REQ'D I PROVIDED 06
FENCE
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DWELLING
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REQUIRED 13 YES
DESCRIBE WORK TO BE DONE
REMARKS
GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:,
VALUATION
Description
Plan Check
HEATSOURCE
LOTSLOPE%
VESTED DATE
Building Permit
PLAN CHECK NO:
Plumbing
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
t: SEPARATE PERMISSION.
Engr. Review
2
M PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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PERMIT LIMIT: SEE ECDC i9.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUC I CESSORS
ud IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
0: INDIRECTLY
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR
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
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
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Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
1AIMCM nO TUE DULY AUTHORIZED AGENT OF
OCCUPANT
GROUP
CONSULTANT
GIVEN IS CORRECT; AND TH I Am InG 0
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
WORKMEW�
,�PEN�ATI��N 11��ANCE AND RCW 118:27.
SIGNATU% W DAT 7-EjY (425)
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FEE Description FEE
State Surcharge
City Surcharge
Base Fee
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Plan Chk. Deposit
Receipt #
Total Amt. Due
Re eipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his1her Deputy: and Fees are paid, and
receipt is acknowledged in space provided
I
FIAALS SIGNATORE DATE
to BY DAW
- ATTENTION EX L I;S;S;J
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL - FILE YELLOW - INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER GOLD - ASSESSOR
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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FINAL PROJECT APM'O VAL FORM
TO:
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MEMO70: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASESIGN
luENGINEERING DIVISION DATE wo
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`PLEASE SIGN
PL G DIVISION DATE
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PERMIT # '2do S ADB# DATEINSPECTED YZU La r
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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
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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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
2.
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date--Signature
1:temp:b1dg:fonns:ocaprv1 3/25/04