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an/ I DATE RECEIVfD [PERMIT EXPIRES
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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OWNER NAME)NAME OF BUSINESS
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STATE LICENSE NUMblIN EXPIRATION DATE
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PRORERTY TAX ACCOUNT PARCEL NO.
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ADDITION COM ERCIAL COMPLIANCE OR
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DESCRIBE WORK TO BE D E
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
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)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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'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
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.,
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 OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
SURANCE AND RCW 18:27,
WORKMEN'S COMPENSATIONA
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DERMIT
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METER SIZE LINE SIZE NO. OF FIXTURES PRV
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REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLJDRAINAGE
DATE
VARIANCE FR71
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ALLOWED PROPOSED
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REMARKS
TYPE OF CONSTRUCTIOIN
GEOTECH REPORT
BY:
STRUCTURAL DESIGN
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Description FEE
Plan Check
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
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FOR INSPECTION Building Official or his�her Deputy and Feosare paid: and
receipt is acknowledged in space provided
(425) OFFICIALS SIGNATURE DATE
771-0220
RE ItA D)TE
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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 / IBC110 IRC110L
PINK -OWNER GOLD ASSESSOR
6/05 PRESS HARD -'YOU A MEMAKING 4 COPIES
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FINAL PROJECT APPROVAL FORM
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DATE:
MEMO TO: PERMITCOORDINATm, BIALDING'DIVISION
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PLANNING DIVISION DATE
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DESCRIPTION OF WORK TO BE INSPECTED f 2y� a i2-
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A field inspection was conducted to determine compliance with -approved plans. Final appOval
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denotes that there are no objections from the -above signed Department to the release of
PERFORMANCE BONDS and the granting of
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GRANT FINAL PROJECT APPROVAL
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GRANT PROJECT APPROVAL Wrr14 CONDITIONS NOTED
0 Copy of. CONDITI ONS given to owner/contractor by inspector.
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FAILED. FINAL INSPECTION - OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE given to owner/contractor by inpector
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RE-[NSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECTAPPROVAL
Date Signature
1:tenip-.b1dg:fonns:ocaprv1 3/25/04