20050913.pdfDATE R"'T.".
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
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CITY
NAME
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NAME
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ADDRESS
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CITY
ZIP TELEPHONE
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PERMIT EXPIRES
PERMIT
NUMBER
J�o SUITE/APTP
ADDRESS (12
7 7 c- I I
PLAT NAME/SUBDIVISION NO.
LOTNO
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LID NO.
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING PROPOSED
TESCPAppmved 0
RW Permit Requiroci 13
Street Use Permit Reqwied 13
inspection Require() C3
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ZIP TELEPHONE
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S ICENSE NUMBER EXFrAj E-�& K:,r
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PROPERTY TAX ACCOUNT PARCEL NO.
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NEW RESIDENTIAL
COMMERCIAL
ADDITION tK
MIXED USE
XREMODEL MULTIFAMILY
REPAIR GRADING CYDS
El DEMOLISH TANK
GARAGE o RETAINING WALL
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CARPORT ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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NUMBER
NUMBER OF
OF
DWELLING
ct
STORIES
UNITS
DESCRIBE WORK TO BE DONE I
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PLUMBING / MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
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OTHER
FIRE SPRINKLER
FIREALARM
Siduwalk Required 13
REQUIRED DEDICATION FT— Undoiground , [3
Wemrj mQuired E3
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YESO NOO z
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REMARKS w
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE z
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ENGINEERING REVIEWED BY DATE
F(E RE. E DATE
JANCE 0)(CU
S RELINE ORADEIN
INSPECTION
SEPA
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REO'D
C3YEs )(NO'
COMPLETED EXEMPT
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CA#
ZONE
SIGN AREA
HEIGH
WAIVER 13
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0 &_
ALLOWED PROPOSED
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ALLOWED PROPOSED
1 3 14- 315-'
STUDY
5r'
LOT COVERAGE
REQUIRED SETBACKS (FT)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT URSIDE REAR
Vic-
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PARKING
LOTAREA
PLANNING REVIEWED BY DATE
REQ , D PROVIDED
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FT.)
REMARKS e-
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SPECIAL INSPECTION
REQUIRED 13YES
RE MARKS
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STRUCTURAL DESIGN
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VALUATION
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Description
Plan Check
HEAT SOURCE
LOT SLOPE7_____F
VESTED DATE
Building Permit
PLAN CK NO:
Plumbing
Mechanical
2—
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
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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
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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 0.
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
Landscapelnsp.
Recording Fee
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
P Ao?l '�7 0
CODE OCCUPANT
2. cv GROUP
CONSULTANT OCCUPANT
FEE
Description
FEE
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State Surcharge
City Surcharge
Base Fee
[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
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IN V1 ' DILATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S COMPEN S�X�U RANCE AN - D RCW 18:27.
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SIGN MR.F (OWNER 0, G�ENT DATESIGNED (425)
771-0220
17
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A)7E-NTIEM 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 I IBC110 / IRC1110.
Plan Chk. Deposit (OW, L
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or hisihar Deputy: and Fees are paid. and
receipt is acknowledged in space provided
FICIALa-SIGNATURK) 11 DATE
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OWNER - GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING.DIVISfON
FROM: FIRE DEPARTMENT DATE /I? -
PLEASE SIGN
ENGINEERING DIVISION DATE
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PIXASE SIGN
PLANNING DIVISION DATE
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PLEASESIGN
PROJECT
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SITE ADDRESS '2-
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PERMIT Wd �5�,QT ADB# DATE INSPECTED
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DESCRIPTION OF WORK TO BE INSPECTED
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'Compliance
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A field inspection was conducted to* determine 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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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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El Copy of. CONDITIONS given to.owner/c.ontractor by inspector
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FAILED FINAL INSPECTION OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE given to owner/contractor by inpector.
2.,
3.
RE-fNSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJ ECT APPROVAL
Date Signatu*re
1:ten1p:b1dg:fonns:ocaprv1 3/25/04