20050796.pdfI
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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
�R NAMEINAME OF BUSINESS
MAILINr
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CITY, ZIP TELEPHONE
NAME
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PERMIT
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PLAT NAMEiSUBDIVISION NO
LOT NO
LID NO
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LID FEE S
PUBLIC RIGHTOF WAY PER OFFICIAL STREET MAP
TESCF`4proved E3
(3
RW Permit R red
s1feet Use =11t, Required 13
EXISTING PROPOSED
inspt�iion Req'1f0d
Sidewalk Required -f�
REQUIRED DEDICATION FT
Underground E3
E3
Winne reiruired
METER SIZE
LINE SIZE
NO OF FIXTURES
PRV REQUIRED
YESE3 NOO
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REMARKS
OWNERiCONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
STATE kICENSE NUMBER
EXPIRATION D TE CHECKED By
VAR.IANCE OR CU
SHORELINE OR ADB#
INSPECTION
REO'D
SEPA
EXEI�JPT
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YES
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COMPLETED
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ZONE
SIGN AREA
HEIGHT
PROPERTY TAX ACCOU TPARCE NO.
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STUDY
ALLOWED
PROPO SED
ALLOWED PROPOSED
NEW
ADDITION
REMODEL
REPAIR
DEMOLISH
E3GARAGE
CARPORT
RSL RESIDE NTIAL
E] COMMERCIAL
MIXED USE
MULTIFAMILY
GRADING CYDS
TANK
RETAINING WALL
ROCKERY
(TYPE OF USE. BUSINVSSs �01RIAC `TV ITY EX,PIAIN:
NUMBER NUMBER OF
LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
PLUMBING / MECH ALLOWED PROPOSED FRONT SIDE REAR FRONT LIRSIDE REAR
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COMPLIANCE OR .3 93 IA tq /C 251 101 z
CHANGE OF USE z
PARKING LOTAREA PLANNING REVIEWED BY DATE
SIGN REO'D PROVIDED
KFEN '2� N /c,
11( j1E X'�(A FT.) REMARKS
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?V0-6UA`ll,1'r TO
EFIRE SPRINKLER
FIREALARM
TYPEVONSTRUCTION ODE OCCUPANT
do GROUP
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STORIES
DWELLING
UNITS
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SPECIAL INSPECTION
REQUIRED 13YES
DESCRIBE WORK TO BE DONE
REMARKS
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GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description
Plan Check
HEATSOURCE
LOT SLOPE"16
VESTED DATE
Building Permit
PLA N CHECK NO:
Plumbing
Mechanical
THIS PERMIT AOTHORIZES 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
Lu
911.
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
to
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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
Fire Review
Fire Inspection
Landscapelnsp.
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
Recording Be
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'11 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
CONSULTANT
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 COMPENS;!:n'*.bQRANCE AND RCW 18:27.
SkN,�TURE NER 0 AGENT): DATq SIG D (4,25)
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levzu�) 771-0220
OCCUPANT
LOAD
FEE Description
State Surcharge
City Surcharge
Base Fee
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Due r_V
(OS
1 Receipt # .21/
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
FIC^S SIGNATUREt) PATEt
NT TT NTION EXT. 1333
IT U WFULTOUSEOROCCUPYA BUILDING OR STRUCTURE UNTIL
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AF IT, INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 f IBC110 I IRC110.
10104 PRESS HARD - YOU ARE MAKING 4 COPIES
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APPROVEDDATE:
ELM Or-FiCIAL
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PERMIT W'n"IBER
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FINAL PROJECT APPROVAL FORM
TO:
DATE.
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
.FROM: FIRE DEPARTMENT DATE
PLEAS11 SIGN
ENGINEERING DIVISION DATE_��/"
PLANNING. DIVISION DATE
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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
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PERFORMA . NCE BONDS and the granting of -
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GRANT FINAL PROJECT APPROVAL
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FAILED FINAL INSPECTION - OUTSTANDING. ISSUES
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL. PROJECT APPROVAL
Date Signature,
Hemp:bldg: forins:ocaprvi 3/25/04
FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASESIGN
ENGINEERING DIVISION DATE
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DESCRIPTION OF WORK TO BE INSPECTED (ol czA ar I a++l'ct -fWcel
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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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RE-INSPECTEDOUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:*fonns:ocaprv1 3/25/04