20050795.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PLAT NAMEISUB DIVISION NO
LOT NO.
LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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Street Use Permit Rectwfud
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EXISTING PROPOSED
inspection R.icjutred
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Sidowalk Required
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REQUIRED DEDICATION FT
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Wiling if-guired
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METER SIZE
LINE SIZE
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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FIRE REVIEWED BY
DATE,
DATE R CU SHORELINE ORAIIIII I INSREEO�ION SEPA
QUECKED F1Y VARIANCE 0 D COMPLETID I EXEMPT
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CA# ZONE SIGN AREA HEIGHT
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LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
FRONT URSIDE REAR
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REPAIR
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REMARKS
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OTHER
GARAGE
RETAINING WALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAJN;
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NUMBER
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NUMBER OF
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LOAD
DESCRIBE WORK TO BE DONE
REMARKS.
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GEOTECH REPORT
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STRUCTURAL DESIGN
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Description
FEE
Description
FEE
Plan Check
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State Surcharge
HEAT SOURCE
LOTSLOPE%
VESTED DATE
Building Permit
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City Surcharge
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PLAN CHECK NO:
Plumbing
Base Fee
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
SEPARATE PERMISSION.
Engr. Review
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
Engr. Inspection
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PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSOR S
Fire Review
Plan Chk. Deposit
ui IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
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, WAIV E OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Landsca peInsp.
Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
Recording Fee
Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION AP 3ROVAL
GIVEN IS 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
This application is not a permit until signed by the
Building Official or hisiher Deputy: and Fees are paid. and
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
receipt is acknowledged in space provided.
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WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
OF SS IGN RE DATE
SIGNATURE (OWNER PWKGEI4T)-'j DATE SIGNED
(425)
771-0220
Rk-LtASI�Eb`13Y I DATE
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ATTENTIONU
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 I IBC110 I IRC110.
PINK -OWNER GOLD - ASSESSOR
10104 . PRESS HARD - YOU ARE MAKING 4 COPIES.
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MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
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ENGINEERING DIVISION DATE—
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DESCRIPTION OF WORK TO BE INSPECTED
-ap roved plans. Final
A field inspection was conducted to determine. compliance with p approval
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PERFORMANCE BONDS 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/contractor by inspector
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FAILED FINAL INSPECTION, OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpcetor
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RE -INSPECTED OUTSTANDING ISSUES7GRANT FINAL PROJECT APPROVAL
Date Signature
1:tenip:b1dg:romis:ocaprv1 3/25/04