20051160.pdfDATE RECEIVED
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PERMIT
CITY OF EDMONDS NUMBER
PERMIT EXPIRES 1--71, 2, z: L
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CITY TELEPHONE
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STATE LICENSE NUMBER EXPIRATION Dt�TE cm By,
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PROPERTY TAX ACCOUNT PARCEL NO
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NEW 2r RESIDENTIAL PLUMBING I MECH
COMMERCIAL COMPLIANCE OR
MIXED USE 13 CHANGE OF USE
EMODEL MULTIFAMILY 11 SIGN
FENCE
REPAIR CYDS 11 ( X FT.)
13 DEM�LISH TANK 0 OTHER
oGARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ROCKERY 1:1 FIREALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
R 115S T It V`% %-
NUMBER NUMBER OF
OF DWELLING, III
STORIES UNITS
DESCRIBE WORK TO BE DONE
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HEAT SOUR F LOTSLOPE% VESTED DATE
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PLAN CHECK NO:
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.
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
'APPLICANT. ON BEHALF OF HISOR 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.'
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
WORKMENI=NSATION INSURANCE AND RCW 18:27.
SIGNATURE)QW0 OR AGENT): DATE SIGNED
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PLAT NAME/SU B DIVISION NO, LOT NO LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApp(ovec!
RW Permil Rwiuir"d
See"t Use Pomil Ri,qui,ed
EXISTING ___ PROPOSED Inspection Requaed
sou*jik Reiluir"d
REQUIRED DEDICATIO14 FT Un,jergrouto
We.nq f"Julln't
NO OF FIXTURES PRV REQUIRED
METER SIZE LINE SIZE T-77.0ad—f YES 13 NO 13
REMARKS
OWNER/CONTRACTOR RESPONS113LE FOR EROSION CONTROIJORAINAGE
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EERING REVIEWED BY
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REVIEWED BY
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ALLOWED PROPOSED
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TYPE OF CQNS
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GROUP
SPECIAL INSPECTION CONSULTANT OCCUPANT
REQUIRED 13YES I I LOAD I
REMARKS
GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
$ /)/I.ImA
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
FEE
Description
State Sur charge
City Surcharge
7A
Base Fee
CALL
FOR INSPECTION
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FEE
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Plan Clik. Deposit
Receipt #
Total Amt. Due
Receipt #
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.
OFFICIALS SIGNATURE % D�TE
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.��TTE TION EXT. 1333
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 if IBC110 / IRC110.
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
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ENGINEERING DIVISION DATE,
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PLEASE SIGN
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PLANNING DIVISION DATE
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DESCRIPTION OF WORK TO BE INSPECTED 00,
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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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PERFORMANCE BONDS and the granting of:
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
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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 -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL.
Date Signature
1:temp:b1dg:fonns:ocaprv1 3/25/04