20000936.pdfDATE RECEIVED
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CONSTRUCTION PERMIT APPLICATION JA
OWNER NAME.AmE OF BUSINESS
MAILING ADDRESS
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ADDRESS
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TELEPHONE
NAME
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ADDRESS
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STATE LICEN E NUMBER
EXPIRATION DATS
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FIRE REVIEWED By
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MECHANICAL
T.I%P..MIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
E GONE ON PF'VA PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
GRADINQIFILL
DOMAIN (CURBS. SIDEWALKS, DRIVE S, MARQUEES. ETC.) WILL REQUIRE
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SEPARATEWPEAYMISSION.
STATE SURCHARGE
PERMIT APPLICATI N: 1800AYS
PERMIT LIMIT. 1 YEAR. PROVIDED WORK IS STARTED WITHIN IBDDAYS
ENG. REVIEW FEES
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
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PLI I FHI OR HER SPOUSE. HEIRS, ASSIGNS AID SUCCESORS
APPLICANT. ON BEHALF o S
OF
END, INSPECTION FEE
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IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY
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THAT I HAVE READ THIS APPTLICATIDN: THAT THE INFORMATION
APPLICATION APPROVAL
HEREly ACKNOWLEDGE
GIVEN CO RECT. AND THAT I AM THE OWNER, 08 HE DULY AUTHORIZED AGENT OF
'S
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TION. AND IN DOING THE WORK AUTHORIZED THEREBY. NO PIERS N.LLBEEMPLOIED
WASHINGTON RELATINGTO
FOR INSPECTION
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IN VIOLATION OF THE LABO CODE OF THE STATE OF
DATE
WORKMEN S COMPENSATION INSURANCE AND RCW 111.27,
ED
SIGNAl E� N
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771-0220
ELF ED By DATE
ATTENTION
EXT/333
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
771-0221
A FINAL INSPECTION AS BEEN MADE AND APPROVAL OR A CERTIFL
I H
ORIGINAL FILE YELLOW INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FAX
PINK -OWNER GOLD ASSESSOR
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FLUE, CHIMNEY AND EQUIPMENT INSPECTION CHECKLIST
Each year before a stove or fireplace is put into service the chimney flue should be thoroughly cleaned
of soot and other residues. Prior to installation of a solid fuel burning appliance in an existing masonry
chimney, the, following items must be inspected by the owner. This form must be completed and
submitted to the Building Division with the permit application.
1. CHRvINEY L]N`ING:
Is the chimney lined with fireclay flue tile, firebrick or other approved lining?
Yes V" —No—
Is the lining in good condition? No voids, cracks or deterioration?
Yes ,-' —No-
2. CLEARANCE TO COMBUSTIBLES:
Are all combustible materials, i.e., wood framing members, a minimum of I" away from the
chimney walls?
Yes--�L_No-
3. GENERAL CONDITIONS:
Is the exterior masonry in good condition, free of cracked or broken liners,,rotten mortar joints
or structural defects? Yes_j��--No_
4. EQUIPMENT:
Have you read the manufacturers instructions for the equipment installation and is the existing
chimney compatible for installation?
Yes__-jL_No—
I hereby acknowledge that I have read these inspection requirements; have personally inspected the
chimney; that the information I given is true and accurate; that I am the owner or the duly authorized
agent of the owner.
Signature DATE
_&1�1 /00
CHIMNEY SAFETY:
Please observe the following warnings in order to install and use solid fuel burning equipment.
1. Use all appliances in the precise manner described and tested by the manufacturer.
2. Follow listing instructions for clearances to combustibles.
3. Inspect chimney flues and appliances yearly for needed repairs.
4. If creosote accumulates in the flue and starts to bum call 911 immediately.
5. Keep an extinguisher on hand and make sure all your smoke detectors work.
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