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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMCNAME OF BUSINESS
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ZIP
ADDRESS
CITY ZIP
NAME
IPERMITEXPIRES L-'jzabl
USE PERMIT
ZONE NUMBER
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ADDRESS 11ITIVAIT,
PLAT NAME/SUBDIVISION NO. LOT NO, LID NO.
11. FEE S
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PUBLIC RIGHT 01 WAY PER OFFICIAL STREET MAP
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EXISTING— PROPOSED- ..p.... .
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REQUIRED DEDICATION— FT
METER SIZE I LINE SIZE I NO,OFlIXTURll YEP V REQUIRED
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OWNFACONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING
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FIRE REVIEWED BY
DATE
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VARIANCE OR CU
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INSPECTION
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C3YES ON
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OSTED
STATE LICENSE NUMBER By
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SERA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED I PROPOSED
HEIGHT
ALLOWED PROPOSED
PROPERTY TAX ACCOUNT PARCEL No.
COD-idl
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EXP
LOT COVERAGE
REQUIRED SETBACKS (Fr.1
PROPOSED ETBACKS (FT.)
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ALLOWED PROPOSED
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FRONT URSIDE HEAR
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CHANGE OF USE
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PARKING
LOT AREA
PLANNING REVIEWED By DATE
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NUMBER
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DESCRIBE WORK TO BE DONE
REMARKS
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P ..... SI..l CTIONS PER UBC 1001FINAL INSPECTION REO
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PROGRESS INSPE A
VALUATION I FEE
PLAIN CHECK FEE
HEAT SOURGE
BUILDING
PLAN CHECK NO:
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT CDVEIS WORK To
SEDoNS ON PRIVATE PROPERTY ONILY. ANY CONST UCTIONON THE PUBLIC
GRADiNGIFILL
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
STATE SURCHARGE
LICATiON: 180 DAYS
PERMIT APPLICATi N: 180 DAYS
PERMIT LIMIT'. I YEAR - PRDVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
s-
F HI OR HER SPOUSE. HEIRS. ASSIGNS AND S
PPLICANT. ON BEHALF 0 S UCCE50RS
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;A
, INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY or
2 EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
1. ALL CLAIMS FOR DAMAGES OF WHATEVER NAl URE. ARISING DIRECTLY RINDIRECTLY
BE
F AOM THE ISSUANCE OF THIS PERMIT SSUANCE OF THIS PERMIT SHALL NOT
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT 0 ANY CITY ORDINANCE
PROVISION.'
ECEIPT
0 NOR LIMIT IN ANY WAYTHE CITY'S A61LITY TO ENFORCE ANY ORDINANCE
TOTAL AMOUNT DUE
[
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
APPLICATION
APPROVAL
I HEREBY
GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
by
THEOWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWSREGULATIN G CONSTRUC
CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, No PERSON WILL BE EMPLOYED
WASH INGTON RELATING TO
F OR INSPECTION ,ipt,� Ilk.c.l.do.d �1_ pd.
IN VIOLATION OF THE LABOR CODE OF THE STAT E OF
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WORKMEN'$ COMPENSATION INSURANCE AND 18.27.
(425)
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771-0220
BE BY DATE
A17ENTION
EXT 333
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IT IS UNLAWFULTO USE OR OCCUPY ABUILOING 08 STRUCTURE UNTIL
771-0221
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI.
ORIGINAL -FILE - YELLOW INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. USC SECTION 109
FAX
PINK -OWNER - GOLD ASSESSOR
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DIVISION DATE—
PROJECT—
SITEADDRESS
PERNIIT 0�(905-? 0 _____--�DATE INSPECTED 2—
�ADB#
DESCRIPTION OF WORK TO BEINSPECTFD
A i5eld inspection was conducted to determine compliance with approved plans. 'Final approval denotes that
there are no objections from the above signed Department to the granting of
approval of the described work
_Performance Bonds associated with the project may be released
FINAL PROJECT APPROVAL
____GRANT FINAL PROJECT APPROVAL WITH CONDITIONS NOTED
_FAILED FINAL INSPECTION - OUTSTANDING ISSUES
2.
3.
p GRANT FINAL PROJECT APPROVAL
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
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Wall..........................
Pier/Porch .................
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Retalni6g Wall ...........
Slab Insulation ..........
PLUMBING:
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Rough -in ...................
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Commercial Final
HEATING:
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Gas Test ....................
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Gas Piping ..............
Equipment
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Commercial Final
EXTERIOR SHEATHING
NAILING ............. ............
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FRAMING ........................
FIRST FLOOR FRAMING
INSULATION ...................
Floor Insulation
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Wall Insulation ...........
Ceiling insulation
SHEETROCK NAILING
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SPECIAL INSPECTION
IT!
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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CITY
;TEllP"llE
NAME
CITY ZIP JTELIIHONE
NA�S M
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ADDRESS
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PI -AT NAME/$UBDIVISION NO.
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REMARKS
.M KIS.1-1--A R—ONSIBLE FOR ERO I OIJDR
__._.TP.,.T_ . FOR EF..,.N OONTR AINAGE
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TATE LICENSE NUMBER
DATE By
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VARIANCE OR CU
SHORELINE OR ADBY
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SEPA REVIEW
SIGN AREA
OYES MNO
HEIGHT
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EXEMPT
ALLOWED PROPOSED
ALLOWED I PROPOSED
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PROPOSED SETBACKS I
NEW
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OWED
ALLOW PROPOSED
FRONT SIDE REAR
FRONT UR SIDE REZT
AUDITION
COMMERCIAL
C MPLIANCEOR
CHANGE OF USE
PARKM
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DATE
REMODEL
[3 APARTMENT
Cl SIGN
LREG-D I I VIDED
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111-ANNINGPEV11WEDBY
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CHEC KEDBY
qUMBER
NUMBER OF
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CIA' NSa
OF
WELL NG
AREAS
REQUIRE0
STO IES
UbTE
NUMBER
C3 YES
DESCRIBE WORK
TO BE DONE
REMARKS
PROGRESS INS
0 CUPANT
GROUP
OCCUPANT
LOAD
PERUBC1
UATION FEE
�LA :CHECK FEE
H LOT SLOPE I
FAT SoURCEND���
BUILDING
k-
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PLAN CHECK NO: TED DATE
PLAN CHECK
PLUMBING
MECHANICAL
THIS PERMIT AUTHORIZES ONLY THE WORK NDTED. THIS PERMIT COVERS WORK TO
I BE DONE ON PRIVATE PROPERTY ONLY. AN' CONSTRUCTION ON THE PUBLIC
91 DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
GRADINGIFILL
SEPARATE PERMISSION.
STATE SURCHARGE
M N:
PER IT APPLICATIO IDO DAYS
PERMIT LIMIT: I AR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
YE
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF 0 HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
'IN
EMNIFY. DEFEND AND HOLD HARMLESS THE
;N INTEREST A=F0 I LESS THE CITY OF
LAND SGA
IClALS.E.Pl-.lEES.ANDA.ENTSFRoMI ANYAND
EDMoM%WASHNGToN F ECTLY
OR INDIRECTLY
INSPE N FEE
CTIo
M FOR. E�ITSOF
All-111 AMA OFWHATEVER NATURE. ARISING DIRECTLY
PERMIT SHALL NOT BE
FROM THE ISSUANCE OF THIS PERMIT BE' F ETH"'
AE-CUEM2M - OF ANY CITY ORDINANC I!
PLAN CHECK DEPOSIT
DEEMED TO .."Y WAIVE.FIIEDUC�AN
ANY ORDINANC
OTE
RE
NOR LIMIT IN ANY W�Y THE CITY'S ABILITY To ENFORCE
TOTAL AMOUNT DUE
D T PL`C o
CKIOW "AT A E IA H Ap AT' N,; THAT THE INIORMAIJON
A DGE T I H V R
APPLICATION APPROVAL
I E EBY C Y A THoRZEo AGENT OF
R F OT THAT . T HE o R HE D U L U
EN E LEAN. Wo'R T W
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CHA S RE ULATN.C..ST.U..
11 P11 I pl-t -11 �19-d by th.
GREE To CoMp' Y W T G Y S T
N I A I H IT AND TA ELA F. WILL BE EMPLOYED
Y NO FE ON
18E oW 'R�
CALL
d, II gb_ I b, bI�,hll Doputy a.d F- - bblb�
Eb"I�
THE ED .
IN A TH ED I
DO G THE W.RKL U .'I
N AND I Co. E OF THE STAT E OF A N
W S I TGN FELATN. TO
H
11
FOR INSPECTION ��j -dgld P'll "I'll
�11— --T�
IN V16LATION OF THE LABOR 18.27.
INSURANCE AN
OFFII A SSIGNATU
WORKMEN'S COMPENSATION
SIG�ED
(425)
77 1,,0220 LEASED B I DATE I
ATTENTION EXT 333
ITISUNLAWF LTO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL 771-0221
U ORIGINAL FILE YELLOW SPECTOR
j"SP r
A FINAL � E _T,.N AS BEEN MADE AND APPROVAL OR A CERTIF) D-ASSESSOR
- UBC SECTION 109 PINK - OWNER GOL
CATE OF OCCUPANCY HAS BEEN GRANTED FAX
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