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CITY OF EDMONDS
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CONSTRUCTION PERMIT APPLICATION
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ADDR f L A-,) k
OWNER NAMEANAME OF BUSIN
PLAT NAME/SUBDIVISION NO,
I LOT No,
LID NO,
_UD FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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EXISTING — PROPO BE(' —
CITY ZIP
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REQUIRED DEDICATION— I
NAME
METER SIZE
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NO, OF FIXTURES
PRV REQUIRED
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YES 13 NO C3
ADDRESS
REMARKS
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROUDRA114AGE
PURSUAN'r 'ro UPC 605.2
CITY ZIP
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NAME
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ENGINEERING REVIEWED/DATE
ADDRESS
FIRE REVIEWED By DATE
CITY
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TELEPHONE
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STATE LICENSE NUMBER DATE
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VARIMCE .. CU
SHORELINE OR ADS#
IN SPECTE130M
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SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOS
17;�I,TStA)M I/AR7�1
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NEW
L, LOT COVERAGE
A OWED PROPOSED
REQUIRED SETBACK$ TD PROPOSED
1-111 SIDE REAR
SETBACK$ (I
FRONT UR SIDE REA
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ADDITION
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PARKING
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LOT AREA
1 PLANNING R IEWED BY DATE
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FENCE
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0 DEMOLISH TANK o OTHER
UB-1 U1 n)r
GGARAGE o RETAINING WALL
ARPORT ROOKERY RENEWAL
(TYPE OF USE. BUSINESS OR AS"
CHECKED —I TYV4.,N
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NUMBER
OF
STORIES
NUMBER OF
DWELLING
UNITS
CRITICAL
AREAS
NUMBER
SPEOCIALEDINSPECTOR
BE U R [:] YES JAREA
OCCUPANT
LOAD
DESC;IBE WORK TO BE DONE
REMARKS
PROGRE2M8*htft40]154WC 409/01higiWSPECTION REC
ffjULAaURVALVh1i—
INIZTAY I rU) NEAR
ATm SHUTOFF
VALUA"u
Plan Check
Mechanical
THIS PERMITAUTHORIZES ONLYTHE ORKNOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. AM CONSTRUCTION ON THE PUBUC
Grading
Z
=1 DOMAIN (CURBS, SIDIZINALKS. DRIVEWAYS MARQUEES, ETC.) WILL REQUIRE
SEPARATEPEAMiSSION.
Engr. Review
PER rrAPPUCATION: 160DAYS
PERMIT UM I I YEAH - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE B,%CK OF PINK PERMIT FOR MORE INFORMATION
'APPLtCAVT ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
Traffic Mitigation
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLE S THE CITY OF
1DMOND1* W SHINGTIIII, Its OFFICIALS. EMPLOYEES, MD AGENTS FROM ANY AND
A
Fire Review
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARIS No DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS P RMIT SHALL NOT BE
MODIFY,
DEEMED TO WAIVE On RE UCE ANY REQUIREMENT OF MY CITY ORDINANCE
01 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION; THAT THE NFORMATION
rlNSPECTI(
GIVEN 13 COBRECT� AND THAT AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
I
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGU ING CONSTRUC-
CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR
WORKMENS COMPENSATIO AND RCW 18.2 .
DATE SIG 'JED
(425)
19-V131- j
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
10101
Recording Fee
City Surcharge
State Surcharge
Plan Chk Deposit
Receipt #
Total Amount Due
Receipt
JCATION APPRbVAL
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ORIGINAL,FILE YELLOW -INSPECTOR
PINK -OWNER GOLD-ASSESSOA
MAL PROJ-E-CT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE —
ENGINEERING DIVISION DATE,419-1:�—
PLANNING DIVISION DATE —
PROJECT
SrrE ADDRESS.
PERMIT # &0 7--o 19 J2 ADB#------PATE INSPECTED 1!110 2-
DESCRIPTION OF WORK TO BE INSPECTED Wodc-
al
A field inspection was conducted to det.rmiue final compliance with approved plans Final approv
denotes that there are no objections from the above signed Department to the release of
PERFORMAN E
BONDS and the granting of:
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
a Copy ofCONDMONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
u Copy of CORRECTION NOTICE given to owner/contractor by inspector
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date— Sign
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing .............
Wall...................... . ..
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Pier/Porch ...............
Retaining Wall ...........
Slab Insulation -
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Underground .............
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Rough -in ...................
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Commercial Final
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10-1
HEATING:
GasTest
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Gas Piping
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Equipment ..........
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commercial Final
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EXTERIOR SHEATHING
NAILING ................
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FRAMING .....................
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FIRST. FLOOR FRAMING
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INSULATION .......... ..........
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Floor Insulation
Wall Insulation ...........
Ceiling Insulation
SHEETROCK NAILING
I'D
SPECIAL INSPECTION
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................