20050759.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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MAILING ADDRESS L/ 7-14
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CITY ZIP TELEPHONE
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NAME
ADDRESS
CITY
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PERMIT EXPIRES
PERMIT
NUMBER
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PLAT NAME]SUB DIVISION NO,
LOT NO,
LID NO
LID FEE
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
Ri,'v Permit Required
EXISTING
PROPOSED
Street Use Permit Requited
Inspection Required
Sidewalk Requited
REQUIRED DEDICATION
FT
Unawgiouna
Wirinq required
METER SIZE
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LINE SIZE T
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NO. OF FIXTURES
PRV REQUIRED
YES 13 NO13
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REMARKS
OWNERiCONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY
FIRE REVIEWED BY
DATE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY VARIANCE OR Cu SHORELINE OR ADBI I INSPECTION. SEPA
REQ'D COMPLETED I EXEMPT
YES A NO
PROPERTY TAX ACCOUNT PARCEL NO. CA# 0 ZONE SIGN AREA
J4 - 1_5_ I HEIGHT
WAIVERD P�'5.1 z' ALLOWED 1OPOSED I AL tOWED PROP9SED
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LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACK (FT.)
RESIDENTIAL PLUMBING if MECH ... ...
NEW ALLOWED PROPOSED �",. 1- "1-1
ide� = � .4
COMMERCIAL COMPLIANCE OR 51 1 Njj�
ADDITION CHANGE OF USE "1 -0 it z
MIXED USE z
PARKING LOTARE PLANNING REVIEWED BY 6TE n
REMODEL MULTIFAMILY SIGN REOID PROVIDED
GRADING FENCE
E] REPAIR CYDS. X FT.)
DEMOLISH TANK OTHER
GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ROCKERY FIREALARM
(TYPE OF USE. BUSINESS OR ACTIVITY) EXPLA
TYP
ROUP
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N BER OF r Ecl nx I'D OF "is
NUMBER U' OCCUPANT
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OF DWELLING SPECIAL INSPECTION CONSULTANT
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STORIES NI S NIA H =ER MUST BE CAP
DESCRIBE WORK TO BE DONE REQUIRE1140 W
REMARKS FROPERT a a
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SE BIB WITH AVB INSTALLED
GEOTECH ITPO
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STRUCTURIA DEMmPAT APPROVED DUMP SITH
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1 O\J I Afr-;l, WIA`U�_ 76 VALUATION SEE MOLITION INSPECTION
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$ C IST ON DOC-
ENIENTS
FOR I PECTION REQUIR
Description FEE Description FEE
Plan Check State Surcharge
HE LOTSL9 VESTED DATE Building Permit City Surcharge
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PLAN Cl-MCK NO: L Plumbing Base Fee
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 Grading
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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PERMIT LIMIT: SEE ECDC 19.00.005(A)(6) Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
V) *APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
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Fire Review
Plan Chk. Deposit
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_1 IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES AND AGENTS FROM ANY AND
'SING
Fire Inspection
Receipt #
0: ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARI DIRECTLY OR INDIRECTLY
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Landscapeinsp.
Total Amt. Due
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
a DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
01 NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
x
Recording Fee
Receipt #
APPLICATION AFPROVAL
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
This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION: AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
CALL
Building official or his/her Deputy: and Fees are paid, and
IN VIOLATIO;m._QF THE LA13OR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
rec owledged in spaceprovided
K N TURE DAT
WORKMEN , qjCOMI-F,,NSATION INSURANCE AND RCW 18:27.
S1 ATURE��VNERORAG`I� P TE SIGNEP
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ATTENTION 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- ORIGINAL - FILE - YELLOW - INSPECTOR
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 1 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 COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
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NGINEERING DIVISION DATE
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PLANNING DIVISION DATE
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PERMIT 7, "59LAbB# DATE INSPECTED'2—
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DESCRIPTION OF WORK TO BE INSPECTED
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A, held inspection was conducted, to determine compliance �with -approved- plans. Final. approval'.
denotes,Ahat there are.' no objections from. the above . signed Department to. the *release: o.f
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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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0 Copy of CORItECTION NOTICE given to owner/contractor b y inpector
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RE71NSPECTED OUTSTANDING ISSUE S - GRANT FINAL, PROJECT APPROVAL'
Date Signature
1:ternp:b1dg:f6=:ocaprv1 3/25/04