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DATE RECEIJED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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PROPERTY TAX ACCOUNT PARCEI, NO.
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
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BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
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PERMIT LIMIT, SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
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IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
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DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.,
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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
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 OFLHE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S CqfPEI%�ATION INSURANCE AND RCW 18;27.
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LOT NO.
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METER SIZE
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NO. OF FIXTURES
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1EMARKS
)WNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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VARIANCE OR CU 5HORELINEORAD130 I INSREFQC�ION I SEPA
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LOT COVERAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT)
ALLOWED PROPOSED FRONT SIDE REAR FRONT URSIDE REAR
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PARKING LOT ATE7A PLANNING REVIEWED BY DATE j
REO'D i PROVIDED I Q.
REMARKS
TYPE OF CONSTRUCTION
SPECIAL INSPECTION
REQUIRED YES
7*M
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr, Inspection
Fire Review
Fire Inspection
Landscapelnsp.
CALL
FOR INSPECTION
(425)
771-0220
EXT. 1333
CODE
CONSULTANT
OCCUPANT
GROUP
OCCUPANT
LOAD
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
ATTENTION - 110, ` I
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. UBC1 09 / IBC1 10 / IRCII 10.
Recording Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or histher Deputy, and Fees are paid. and
receipt is acknowledged in space provided
OFFIC14L$ E?C*NATURE /DATE i
RELEASED BY
6/05 PRESS HARD - YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
N1 EIAO TO: PE T rt� 0 0 ILDING DIVISION
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FROM: C, FIRE DEPARTNIENT DATE
PLLASE SIGN
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ENGINEERING DIVISION DATE
NEASL S16"
PLANNING DIVISION DATE
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PROJECT
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SITE ADDRESS:. 5 3
077 DATE INSPECTED
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DESCRIPTION OF WORK TO BE INSPECTED f IS
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A field inspection was conducted to determine compliance ii -ith -approved plans. Final ipproval
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I -trnent to the release of
denbtes that thei -e are -no objections from the hove signed' Depai
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PERFORMANCE BONDS and the granting of.:
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FINAL. PROJECT APPROVAL
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
C1 Copy of CONDITIONS given to o%N -ner/contractor by'inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE giv -en to owncr/contractor by inpector
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RE -INSPECTED OUTSTANDING ISSUES. - GRANT FINALTROJECT APPROVAL
Date Signature
1:1emp:b1dg:fbmis:ocaprvI 3!25/04
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