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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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;TATE LICENSE NUMBER
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ALLOWED PROPOSED
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BY "AT'
BE.,. I PROVIDED I
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QCHECKED BY TYPE F CONSTRUCTION
CTOR AREA
ECIAL NS OCCUPANT
pLOAD
IOUIR11D [TYES
PLAN CHECK FEE
VALUATION FEE
GLAZING I LOT SLOPE %
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BUILDING
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PLAN CHECK NO: �VESTEO DATE
PLUMBING
MECHANICAL
THIS PERMIT AUTHDRZES=EWoYK N.oTlo "IS PERMIT COVERS WORK TO
A �.T TRUCTION ON THE P BLIC
Y NL C S u
GRADINGIFILL
ON PRIVATE
BE DONE .
oMAiN ICURBS, SIDEWALKS, DRIVEWAYS' MARQUEES, ETC.) WILL REGUME
SEPARATE PERMISSION.
59M SURCHARGE
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT, 1 YEAR - PROVIDED WORK IS STARTED WITHIN 18. DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
ENG INSPECTION FEE
'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUGGESORS
IN INTEREST, AGREES TG goE_N,,,,y4LDEFEND ANEESolD HARMLESS THE CITY OF
AGENTS FROM ANYAND
LANDSCAP NO
FEE
I EDMONDS. WASHINGTON T, FF '. E.,L, AND
ARISING DIR OR IND RECTLY
INSPECTION
RECEIPT
Ib ALL CLAIMS FOR CAIVA E� OF WHATEVER NATURE. ECTLY
PERMIT. ISSUANCE OF THIS P RMIT SHALL NOT BE
PLAN CHECK DEPOSIT
% FROM THE ISSUANCE OF THIS
WAIVE OR REDD ANY REQUIREMENT OF ANY CITY ORDINANCE
D EMED Tjo MODIFY.
E WAY THE CITYS ABICITY TO ENFORCE ANY ORDINANCE PROVISION
D NoRLIMI INANY
RE
TOTAL AMOUNT DUE
EIPT
2�
VIATION
APPLICATION APPROVAL
-
VrETT.H�ATI: -AVTE��1,DT,,SApLCATol�,"ATT�E�N'C
I HEREBY ACKN WNER OR THE GUL AUTHORIZED AGENT OF
HE(
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T NO AM
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IS CORR L.AW ' `�',GNU LATLN.GECo I S T R U C
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CALL
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THE I AG R E E TO RTA�TyE
OWNER. N PER WIL EMPLOYED
TION AND IN DOING THE WORK AUTHoRIZED T
RELATING TO
FOR INSI
llldqod,� F,co P?0vtdod
IN VTCLATION OF THE LABOR CODE 0 THE STATE OF SHINGTON
WORK!��MPENSATION IySURANCE AND
sIdE WTE (OWNE' DATE
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(42%0
DATE
771-02
L SED By
EXT 333
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
YELLOW - INSPECTOR
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ORIGINAL - FILE
GOLD ASSESSOR
UBC SECTION 109
FAX
PINK -OWNER
CATE OF OCCUPANCY HAS BEEN GRANTED.
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-ECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
'SETBACKS ......................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch .................
Retaining Wall ..........
Slab Insulation ..........
PLUMBING:
Underground .............
Rough -In ...................
Commercial Final
HEATING:
Gas Test ....................
Gas Piping .................
Equipment .................
Commercial Final
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ...............
FIRST FLOOR FRAMING
INSULATION ...................
Floor [mutation
Wall Insulation ...........
Ceiling Insulation
SHEETROCK NAILING
SPECIAL INSPECTION
F
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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DATE RECEIVED
CITY OF EDMONDS
ONSTRUCTION PERMIT APPLIdATION
MAILING ADDRESS
CITY
ZIP
TELEP"p
NAME
[PERMIT
EXPIRES
... PERMIT
ZoN, 0-
NUMBER
JOB SUITEP,PT*
ADDRESS
PI -AT NAMEISUBDIVIStON NO.
LOT NO,
UO 00-
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
=p"'ll
P A"'I"
ING — PROPOSED -
S.—N ftan-
REGUMED DEDICATION— FT
PRY BE. ED
YES . NO C3
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
A,(l ""I-
ENGINEERING
A 'S
DDRESS
PQL"�Ub
DATE ba
FIRE REVIEWED BY
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CITY
TELEPHONE
C>
INSP—ECTION
STATE LCENSE �NUMBSR
E—B—N E RECKED BY
VARIANCE OR CU SHORELINE OR ADBN
I PBOND
OSTED
E3 YREQ'D
ES ON?
'.Juaf)z vil g
PRO TAVCCOUNT PARCEL NO.
SERA REVIEW SIGN AREA
COMPLETE I EXEMPT ALLOWED PROPOSED
HEIGHT
ALLOWED , PROPOSEI
n V onan
EXP
LOTGOVERAGE REQUIRED SETBACKS IFT)
PROPOSED S TDACKS jFT.)
NEW
PLUMBING I MECH
ALLOWED PROPOSED FRONT SIDE BEAR
FRONT UR S DE REAR
E] ADDITION
cl CO PLIANCE OR
CHANGE OF USE
PLANNING REVIEWED By DATE
0 REMODEL
SIGN
C] REPAIR
0 ..ABIN. CYDS
FINGE X
REMAHKS
DEMOLISH
C] TANK.
OTHER
GARAGE
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0 RETA�INIMNYG WALL 0 RENEWAL
BOO F
YPE . US.. BU7'S ORA(3TIVIIII EXPLAIN;
OHEOXEo By RUCTION CTE
G.C(3LIPAN)?
NUMBER
NUM8EROF
0 ITICAL
Slj_._lAL 1�iPE
OCAD—N I
da
a
OF
STORIES
DESCRIBE WORK TO BE
0 WELLING
UNITS
DONE
AREAS
NUMBER.
REQUIRED
REMARKS
LO
PROGRESS INSPECTIONS PER UBC IAI INSPECTIONREO'DI, 91
C F
PLAN CHECK FEE
P L A N H K
L o P E
LOT SLOPE %
L a T S
I o I N G
BUILDING
B U L
PLAN CHECK NO: S T E o o A T E
L
PLUMBING
P M I
U
N C A L
SCHANICAL
C H A
E R M I T C o V E R W o K To
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED, THIS PERMIT COVERS WORK TO
I C T I N o E P L
BE .ME ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
I L L
GRADING/FILL
A B I N
I..
E T I W I L L U B
..A,. (BUE.S. SIDEWALKS, DRIVEWAYS MARQUEES, ETC.) WILL REQUIRE
SEPARATE PER�Isslobl.
-
R E
9"M SURCHARGE
S C
P RMlTAPPUCATION: lBD.AYS
E
I W I T ' B A Y
PERMIT LIMITI I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
FE S
ENG. REVIEW FEES
N E E W
I o N
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
A S N S A N SUt`C E..RS
P ON BEHALF 01 HIS OR HER SPOUSE, HEIRS, ASSIGNS AND lUlclSORS
*A PLICAMT.
11"E
T N FEE
I..
ENG. INSPECTION FEE
EN. N , E
H A R L E S THE CITY OF
IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
FROM ANY AND
'B". ANY AND
C I N -FA
S Ap
LANDSCAPING
LAND
I. AGENTS
EamoNDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS
DIRECTLY OR INDIRECTLY
ALLCLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLYOR INDIRECTLY
E. T N EE
INSPECTION F E_
IN P
S E MI ERA" NOT BE
FR THE 1-.A�CE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHECK DEPOSIT
PLAN OR CK DEPOSIT
DEoEMEDT MODIFY. WAIVE OR REDUCE ANY REQUIRE.ENTOF ANY CITY ORDINANCE
o o ION -
C
0 NOR LIMIT IN ANY WAYTHE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.
TOTAL AMOUNT DUE
T
IHERE5 ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION, THAT THE INFORMATION
Y
Y AUTHORIZED AGENT OF
GIVEN I S CORRECT.ANDT AT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
R ULA I N CoNST C-
THE OWNER I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC
C LL
CALL
DIN THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
TION. AND IN o W, L, P Y
RELATING TO
G S , T. EL T, G To
0 1 PE CTI,
FOR INSPECTII
S
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON
Won��MPENSATIONI�SURANCI AND HOW 11,11
CATE SIGN ED
(425)
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771-0220
EXT M
ATTENTION
IT IS UNLAWFULTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
519.
VALUATION I FEE
APPLI ATION APPROVAL
Tul 11 li..ts I. net . p—il until."na,l by I'.
..'aln 011mill 11 hleher Deputy: and F .1. ba,d. and
d,pI,. .,,kn..l.d,.,,n IF— pd.d.
AloE
2,
ErLEX§ED BY DATI!
ORIGINAL -FILE YELLOW- INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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CITY OF EDMONDS NUMBER
EIAPT
CONSTRUCTION PERMIT APPLICATION joa SUITEIAPT
ADDRESS
OF BUSINESS
OWNERNAME)NAME
71�1-ivls (L CHECKrBDIVISION NO 0
MAILING ADDRESS
1, REET MAP. TESCPApp,..d
RIGHT OF WAY PER OFFICIAL ST
PUBLIC
IN
RW Pmmll Required
EXISTING — REQUIRED DEDICATION street ON, Permit ReFfd
m 1 lm,�Il Required 1k
NAME
ED ItTir
PAV Cut ED
ETERSIZE LINESIZE NQOI_��URES PRI REQUIR
YES 0 No D
ADDRESS
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CITY 11 NU&I 6;2L
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NAME—
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ACORES S
ENGINFERI 'I.-ED BY
CITY ZIP To EPHONE NUMBER
UITT
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STATE LICENSE NUMBER
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Legal Deacription of Property - Includewall-easOments
_VARIANCE
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SIGN AREA HT
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REQUIRED SETOAcivs (FT' PROPOSED SETBACKS (FT)
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0 GARAGE [] RETAINING WALLI RENEWAL
13 YES
REMARKS
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CARPORT ROOKERY
OF, ACTIVITY'
PROGRESS INSPECTIONS PER UBC 108,
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9 (TYPE OF USE. BUS NESS
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NUMBER NUIIE181R 0 AR
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ITIO
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ES.AI.E.ORKTO. ONE'ATTACH PLOT PLAN,
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FINAL INSPECTION REOUIRED
VALUATION
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PLAN CHECK FEE
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BUILDING
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HEAT SOURCIP. GLAZING
r
PLUMBING
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MECHANICAL
ITI
covers work to be doneon rivateproperty NLY.
GAADINGIFILL
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domain (curbs
to ,�Ic
d.1 'awag require separai� per issio;.
=.O.�,
STATE SURCHARGE
P 11 A, I Days
STORM CRANAGE FEE
son 11 1,13111. Provided Work Is Started W IthIn 180 Days
Applicant, on behalf of his or her spouse irs adssignstand
END. INSPECTION FEE
in Interest, agrees ino' d f�n nd Od
c .... O's dom f�he
dto
a S'
harmless the City of,Edmon it Washington, it official
1:nd
4 L
To all claims or damage. of
employ:SS nd S.grahtnso m any
to G. . directly or Indirectly from th a is ... rice
h.av hoe
this Shall not be deemed to
PLAN C E DEPOSIT
of this permit - Issuance of permit
modify, waive or reduce any requirement of any city ordinance
0. nor limit in any way the Of -. hilli, to enforce any ordinance
TAI
provision."
edge..._...._-____ - 1.
A PLICATION APPRO
InlormallOrT given Is Correct; and that I am the owner. or the duly
�l
It . hgr..,n�gneahl, comp y with city and
au h."Ziso ant 0, th Ow 1.
PERMIT permit until
THIS �hls application is nota
U . d d.irt In work authoriz.
is jaws regulating const rL
hS
AUTHORIZES I
ONLY THE signed by the Building 0 cial or his/her
n of he Labor
b no 0 roon W" bg em�loyed In violatio t
d 'hes Y� Pit
WORK NOTED Deputy; and fees are paid, and receipt Is
Cod. of th ., .1 Washington rehiting to Workmen's Compensa.
S
acknowle god in space provided,
lien Insurance aria R W1119
TE SIGNE
r1)NSPEC ION
EPAITTMENT
I ATURE (OWNER OR AGE TI OF ICIAL�5 SIGNATURE
'2 -- 0 - CITY OF WE
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L"
EDMONDS r",
CALLFOR
ATTENTION Z5e—ji" �14
INSPECTION J
IT IS UNLAWFUL T?PEUCSTE,OOR HCACSCUPY A MA'L__XN,�� R STRUCTURE RIGINAL - File YELL W - InsPeCIO1,
N BEEN 0 A .... AL OR 771-0220 0
LIN L INS
T'L A F:C G A US GOL Assessor
NA OF N C
A CERTI1 ATE OCCUPANCY HAS BEE R PINK - O.,.e,
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