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PERMIT EXPIRES
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PERMIT ;zoo
CITY OF EDMONDS
NUMBER
9
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CONSTRUCTION PERMIT APPLICATION 1
ADDRESS
OWNER NAMEMAMEOFBUSII ESS
NO
LOT No'
LID NO.
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MAILING ADDRESS
PUBLIC RIGHT OF WAY PER OFFICIAL
STREET MAP
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EXISTING � PROPOSED
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REMARKS
SAINAGE F,
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NAME
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ENGINEERING REVIEWEDOATE
ADDRESS
FIRE REVIEWED By DATE
ZIP
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VARIANCE OR CU
SHORELINE OR ADII
11
0
STATE LICENSE NUMBER IRATION DATE CHK*MWY
MO AIRD/SlA
SEPA REVIEW
COMPLETE EXEMPT
EXP
SIGN AREA
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EMARKS
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REMARKS
OGRESS INSPECTIONS PER UBC IOWFINAL INSPECTION REG'
7'
VALUATION
FEE
PLAN CHECK FEE
HEAT SOURCE GLAZING % I LOT SLOPE I
E
BUILDING
PLUMBING
PLAN CHECK NO: 1,111100ATE
MECHANiCAL
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THIS PERMIT AUTHOR ,Z,, ONLY THE WORK ".TE AS WORK TO
C.
BE GONE AT.PR.PEATYgLYA�, ,T.SlEA.ITCOVE
ON PRI STRUCTION ON THE PUBLIC
V
GRAOING/FILL
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DOMAIN (CURDS. SIDEWALKS, DRIVEWAYS. MARQUEES. ETC.) WILL A 0 IRE
STATE SURCHARGE
SEPARATE PERMISSION.
PERMITAPPLICATI 4: 1-B-AYS
PERMIT LIMIT'. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
ENG. REVIEW FEES
SEE BACK OF
ENG. INSPECTION FEE
-APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS,
THE CITY OF
LANDSCAPING
INSPECTION FEE
IN BREST AGRl.ESCTO:NI)E N' DEFEND AND HOLD HARMLESS
IN' S. SHIN O`FFIICI�LS. EMPLOYEE& AND AGENTS FROM ANY AND
EIDMOND WA
DEPOSIT
RECEIPT
T DIRECTLY
C L CLAIMS FOR DAMAGES OF WHAT NATURE. ARISING DIREC LYORIN
C AL PERMIT,SHALL NOT
A%1TER
FROM THE I NCE OF THIS PE M . ISSUANCE OF THIS
�il!� OR REDUCEANY REOUIREMENTOPANYC TYORDINAN
PLAIN CHECK
DEE.EDTO FlWAIV
NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISIO
TOTAL AMOUNT DUE IS
CEI"/,o g Ao
I HEREBY ACKNOW EDGE THAT I HAVE READ THIS APPLICATION. THAT THE INF.A.AT, N
L " ED AGENT OF
GIVEN IS CORRECT. A D I "AT I AM THE OWNER. OF' THE DoLYAUT"oT '.
THEOWNER iAGAEETOCOVPLY STATE,. EGU, 1. C.�STRUC
7 WITH CITY AND
TION. AND IN DOING THE WORK AUTHORIZED THEREBY, NO FIE ON WILL BE EMPLOYED
IN VIOLATION L BOB CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN E, TIONIN SURANCE AND RCW 18.21,
CALL
FOR INSPECTION
APPLICATION APPROVAL
ThIl �PPI'lltlln a q,I ..III 11911d by tlo
B,�Ild.,,g Ofl,C.aL 11 Dop.ty: and F... .1. P� and
o,,.Pt.. c�nowlldgUd In vaFa F—ded.
OF T BE
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(425)
771-022
-MRELEKSWBY F
ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
ON 109
EXT 1333
771-0221
CAY
ORIGINAL - FILE - YELLOW - INSPECTOR
PINK -OWNER - GOLD -ASSESSOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTI
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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
items must be inspected by the owner. This form must be completed and
chimney, the following
submitted to the Building Division with the permit application.
1. CHIMNEY LINING: tile, firebrick or other approved lining?
Is the chimney lined with fireclay flue
Yes--2L--No—
Is the lining in good condition? No voids, cracks or deterioration?
Yes--,X—No-
2. CLEARANCE TO COMBUST113LES:
Are all combustible materials, i.e., wood framing members, a minimum of I" away from the
6i
2 A!,
M.
chimney walls?
Yes �4 —NO-
0
3. GENERAL CONDITIONS:
Is the exterior masonry in good condition, free of cracked or broken liners, rotten mortar joints
or structural defects?
Yes_y —No_
4. EQUIPMENT:
Have you read the manufacturers instructions for the equipment installation and is the existing
r
chimney compatible for installation?
have inspected the
I hereby acknowledge that I have read these inspection requirements; personally
is that I am the owner or the duly authorized
chimney; that the information given true and accurate;
agent of the owner.
L
ai
Sig.atu,e_
_,�
CHIMNEY SAFETY:
Please observe the following warnings in order to install and us e solid fuel burning equipment.
P.
1. Use all appliances in the precise manner described and tested by the manufacturer.
2. Follow listing instructions for cl earances to combustibles.
3. Inspect chimney flues and appliances yearly for needed repairs.
in the flue and starts to bum call 911 immediately.
accumulates
4. If creosote ur smoke detectors work.
5. Keep an extinguisher on hand and make sure all yo
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
i pi
FOUNDATION:
Fooling ......................
wall..........................
Pier/Porch .................
C)
RetaInlng Wall ...........
Slab Insulation .......... r:
PLUMBING:
Underground ...........
Rough -in ...................
Commercial Final
M
HEATING:
Gas Test
....................
Gas Piping .................
A
Equipment ;; ...............
C ormnerclal Final
M
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST FLOOR FRAMING
INSULATION ...................
r
Floor Insulation
Wall Insulation ...........
Coiling Insulation
SHEETROCK NAILING
M
SPECIAL INSPECTION
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
IC)l
.. . . ......
EXPIRES
PERMIT
ClW OF EDMONDS
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PERMIT 9 1--o ;z _7*
NUMBER
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CONSTRUCTION PERMIT APPLICATION
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NAMUSUBDIVISION NO,
LOT No'
LIO NO. J
Al
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LID FEE I
X
MAILING ADDRESS
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PUBLIC RIGHT OF
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CITY ZIP
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ITELEPHONE
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STATE LICENSE NUMBER
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SEPA R�IVIIW
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EXP
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CHANGE OF USE
PA R
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ENCE
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GROUP
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NUMBER
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ICAL
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NUMBER
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SPECIAL INSPECTO
S
OU 'R
REQUIRED E] YES
YES
AREA
C.C.URANT
LO
10
DESCRIBE WORK TO BE DONE
REMARKS
RnGIRESS [INSPECTIONS PER USC 1081WFINAL INSPECTION REG
P pnna
c K E E
PLAIN CHECK FEE
P LA N C H
HEAT SOURCE GLAZING %
E
LOT SLOPE %
N G
B ILDING
U 'L D I
PLAN CHECK NO:
IVESIED-1
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P U ME
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A N C AL
MECHANICAL
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IN o K T
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
U
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBU c
L
GRADINGIFILL
RA I N 'L
- I
DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS "AROIJEES. ETC,) WILL REQUIRE
SEPARATE PER�ISSION.
C R G E
STATE SURCHARGE
T AT E S
PERMIT APPLICATION: 190 DAYS
S
PERMIT LIMIT'. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
V EW E ES
ENG.REVIEW FEES
EN R E
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
T I. N
ENG. INSPECTION FEE
END IN S ED
A CCE....
ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
;APPLICANT,
N INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HAR.L = CITY OF
Ap
LANDSCAPING
LANG
E
ANY A..
EDMONDS. WASHINGTON, ITS OFFICIALS. EMPLOYEES. AND AGENTS FRO. AIIY.D
D RE-TLY
AULCLAtMS FOR DAMAGESOFW"ATEVER NATURE.ARISING DIRECTLY OR INDIRECTLY
T I N EE
INSPECTION FEE
INS F E. "
L T
N BE
1. FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
PLAN CHICK DEPOSIT
PLA C . P
N c""' K E T
DEEMED TO MODIlY.WAIVl OR REDUCE ANY REQUIREMENT OFANY CITY ORDINANCE
SION.'
0 NOR LIMIT IN ANYWAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROV'S'
TOTAL AMOUNT DUE
I HERE Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT. AND THAT I AM THE OWNER OR THE DULYAUTHORIIEDPAGENTOII
T EOWINER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC.
H
CALL
EMPLOY G
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
TI(
IN VI CODE OF THE STATE OF WASHINGTON RELATING TO
WOR
FOR INSPECTH
lo; NED
(425)
!��MNT)
JZ
1 0 0
771-0220
ATTENTION
EXT 1333
IT IS UNLAWFUL TO 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
*8
VALUATION FEE
0 Uv I lq_�p -
liPPLICATION APPROVAL
Pplf�w is not a perntl unt.1 519— by —
OIL—, ., hiion,s, D.PuI,:.,td F.—I. 1.1d. no
,pt jsntodg,dp,os p—ded.
ORIGINAL nLE - YELLOW - INSPECTOR
PINK - OWNER - GOLD - ASSESSOR
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