20051171.pdfDATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUS NESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
Skoye.,�ivit,
NAME
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ADDRESS
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ZIP TELEPHONE
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STATt LICENSE NUMBER EXPIRATION DATE
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PROPERTY TAX ACCOUNT PARCEL NO.
00943q00010000
NEW
RESIDENTIAL
-SOMMERCIAL
ADDITION
MIXED USE
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
GARAGE
CARPORT
RETAINING WALL
ROCKERY
(TYPE OF USE. BUSINESS ACTIVITY) EXPLAIN:
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NUMBER
4JMd
OF
MWEL
STORIES
UNITS
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PLUMBING / MECH
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COMPLIANCE OR
CHANGE OF USE
G;KSIGN
FENCE
X FT
OTHER
FIRE SPRINKLER
FIREALARM
PERMIT EXPIRES
PERMIT
NUMBER
JOB
ADDRESS
SUITEIAPTO
77=,NAMEISUBDIVISION NO.
LOT NO.
LID NO.
LID FEE S
�UB�LIC Rl&�T OFrOAY PER OFFICIAL STREET MAP
TLSCII Approved
RW Peirri.t Requaral
EXISTING ��LP.'G �OPOSED
Street use Permit Requited
Inspection Requited
Sicre6alK Required
REQUIRED DEDICA1 ION
FT
underground
Waing required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YESO NOO
REMARKS
OWN E R/CONTR ACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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(2-/2 7/v-_S
DATE
FIRE REVIEWED BY
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION SEPA
REO'D COMPLETED I EXEMPT
13YES ENO I A
CA# ZONE SIGN AREA HEIGH
0WAIVER ALLOWED PROPOS ALLOWED PROPOSED
OSTUDY BIC '56 CA I q - I � 10 101 '9 110 Iclej
LOT COVE RAGE REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/RSIDE REAR
C>I C>' 1151 NOCHAt4CIC-9
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PARKING LOTAREA 1. PLANNING REVIEWED BY DATE
REO'D PROVIDED 911.
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REMARKS
SPECIAL 114SPECTIO1
REQUIRED DYES
BY:
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Description FEE
HEATSOURCE LOT SLOPE9 - ----- 7f VESTED DATE Plan Check
Building Permit
PLAN CHECK NO: 00
7c) Plumbing
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Mechanical
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION. Grading
OCCUPANT
GROUP
OCCUPANT
LOAD
Description
State Surcharge
City Surcharge
Base Fee
FEE
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PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
Engr. Review
Recording Fee
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PERMIT LIMIT* SEE ECDC.19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
Plan Chk. Deposit
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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
Fire Review
Receipt #
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EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Total Amt. Due
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.,
Landscapelnsp.
Receipt #
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
CALL,
This application is not a permit until signed by the
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
Building Official or hisiher Deputy* and Fees are paid. and
FOR INSPECTION
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
receipt is acknowledged in space provided
WORKMEN'S COMPENSATMURANCE AND RCW 18:27.
OC9'M%tALS SIGNUURE D
SIGNATURE (OWNER OR "GEN DATE SIGN D
(425)
771-0220
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9116
EXT. 1333
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ATTENTION
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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 1 IBC110 / IRC110.
PINK -OWNER - GOLD - ASSESSOR
6105 PRESS HARD - YOU ARE
MAKING 4
COPIES
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HNAL PROJECTAPPROVAL FORM
TO:
DATE:
MEMO'rO: PEIZMITCOORDINATOR, BUILDING DIVISION
FROM:. FIRE DEPARTMENT DATE
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DESCRIPTION OF WORK TO BE INSPECTED 3)
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A field inspection was conducted to determine compliance w ith -approved plans. Final ap&oval
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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 PROM CT APPROVAL
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
El Copy of CONDITIONS given to owner/contraclor by inspector.
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FA-ILED FINAL INSPECTION OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE r/contractor by inpector
given to owne
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GIZANT. FINAL 11ROJECTAPPROVAL
Date Signature
1:temp:b1dg:fonns:qCaprv1 3/25/04