20050944.pdfI
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
MAILING ADDRESS
CITY ZIP MTELEPHONEtp
ADDRESS
NAMt
236rz
ADDRESS
CT P kELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE
'9411
PROPERTY -TAX ACCOUNT' PARCEL NO.
NEW
RESIDENTIAL
PLUMBING/MECH
ADDITION
1;;U/COMMERCIAL
I
/COMPLIANCE OR
-_,�MIXED
USE
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING
CYOS
o FENCE
X_
DEMOLISH
TANK
Erg& I C;
UGARAGE
o
RETAINING WALL
FIRE SPRINKLER
1-1
CARPORT
ROCKERY
FIREALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
P6RM_1T
NUMBER
JOB
ADDRESS
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PERMIT EXPIRES
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SUITE/APT#
PLAT NAMEISUBDIVISION NO.
LOT NO
LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved [3
RVV Permit Required [3
Street Use Permit Required E3
EXISTING PROPOSED
Inspoci,on Required Cl
SiCewalk Required
REQUIRED DEDICATION FT
Underground
C3
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YESO NO 0
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY
DATE
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A R I ANC
RIANCE CU
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SHORELINEORADB#
RED 'D
I INSPECTIONOI
13 YES 13 N
SEPA
COMPLETED I EXEMPT
Y
Y
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ZONE
SIGN AREA
HEIGHT
W A IV
WAIVER 13
E R 3
ALLOWED PROPOSED
ALLOWED PROPOSED
T
STUDY 13
S U D Y 3
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LOT COVERAGE
LOT OV[
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LIRSIDE REAR
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PARKING
R E Q_'_D PROVIDED
LOTAREA
LANNING REVIEWED BY DATE
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REMARKS
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TYPE OF CONSTRUCTION
CODE
OCCUPANT
GROUP
NUMBER
OF
STORIES
NUMBER OF
DWELLING
UNITS
SPECIAL INSPECTION
REQUIRED
CONSULTANT
OCCUPANT
LOAD
DES9RIBE WORK TO BE DONE
REMARKS
GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEATSOURCE
LOT SLOPE%
VESTED DATE
Building Permit
City Surcharge
PLAN CHECK NO:^
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE IkRK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY C014STRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Grading
ngr. eview
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PPRMIT LIMIT: SEE ECDC 19.00,005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
'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
NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION.,
Fire Review
Plan Chk. Deposit
Fire Inspection
11)1012
Receipt #
Landscapelnsp.
Total Amt. Due
Recording Fee
--[Receipt
#
1 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
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
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27,
CALL
FOR INSPECTION
15)
(425
771-0220
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.
S E DATE
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SIGNATURE (OW
,,,t;9%7j
DATE SIGNED
Da -V TA
AT tE4TION EXT. 1333
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 744L,/
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI- ORIGINAL -FILE YELLOW - INSP(CTC
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 / IBC110 / IRC110. PINK -OWNER GOLD - ASSESSOR
10/04 PRESS HARD - YOU ARE MAKING 4 COPIES
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FINAL PROJECT,kPPROVAL FORM
TO:
DATE:
MEMO TO: C UILDING DIVISION.
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FROM: FIRE DEPARTMENT DATE/eF
PLEASE Sit;
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DIVISION DATE
—ENGINEERING
PI.F.AS17 SIGN
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PLANNING DIVISION DATE.
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PLEME SIGN
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PROJECT A6va<"6z_
SITE ADDRESS 4v
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PER -MIT # 9P5'-_19r4q ADB# DATE INSPECTED
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DESCRIPTION OF WORK TO BE INSPECTED howe
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A field inspection was conducted to determin'e complia -ith -.a -ed pl. al approvil
nee ii ppro% ins. Fin.
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denotes that there are no Objections from the above signed Department to the release of
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PERFQRI%IANCE BONDS and the granting*of:
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RANT FINAL PROJECT APPROVAL
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GRANT PROJECT A11PROVAL WITH CONDITIONS NOTED
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El Copy of CONDITIONS given to oxviler/confractor by inspector
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FAI.LEDFINAL INSPECTION - OUTSTANDING ISSUES
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Copy of CORRECTION NOTICE given to owner/contractor by hipector
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:tejnp:b1d9:fomis:ocaprv1 3/25/04