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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEMAME OF BUSINESS`__��'
MAILING ADDRESS
CITY ZIP ITELEPHONE
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NAME_�
ADDIE
CITY "'pP TELEPHONE
NAME
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ADDRESS
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CITY ZIP TELEPHONE
STATE LICENSE NUMBER
EXPIRATION
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NEW
rl RESIDENTIAL
ADDITION
COMMERCIAL
REMODEL
APARTMENT
REPAIR
GRADING CYDS
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E] TANK
oGARAGE
o RETAINING WALL
CARPORT
ROCKERY
[TYPE OF USEqUSINqSS
OR ACT I IN:
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Ill NUMBER.
NUMBER OF
OF
DWELLING
01 STORIES
UNITS
-1 DESCRIBE WORK TO BE DONE �,
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CHECKED BY
PLUMBING / MECH
COMPLIANCE OR
CHANGE OF USE
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RENEWAL
CRITICAL
AREAS
NUMBER
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HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHECK Ngj-. VESTED DATE
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180DAYS
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PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
(n 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST. AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
.4
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
5 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
GIVEN IS CORRECT, AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
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
WORKMEN'S SPMEENSATION INSURANCE AND RCW 18.27.
iii A DATE SIGNED
__�SIGNATrr�HE (PYAN 46ENT)
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PLAT NAME/SUBDIVISION NO
PERMIT EXPIRES
PERMIT
NUMBER
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ILOT NO. LID NO.
I'D FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
METER SIZE I LINE SIZE I NO. OF FIXTURES
TESCP Approved
13
RW Permit Required
(3
street use Permit Roq.d
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Inspection Required
13
Sidewalk Required
E3
Undergiound
wiring required
(3
PRV REQUIRED
YES 13 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING
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ALLOWED PROPOSED
ALLOWED PRPPOSED
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EXP
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REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (Fr.)
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PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D
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ATTENTION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. USC SECTION 109
10/01
VALUATION $
FEE I Description I FEE
Plan Check
Building
Plumbing
Mechanical
Grading
Recording Fee
Engr. Review
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City Surcharge
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Engr. Inspection
State Surcharge
Traffic Mitigation
Plan Chk Deposit
Fire Review
Receipt #
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Fire Inspection
Total Amount Due
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Receipt #
APPLICATION APPROVAL
CALL
This application is not a pernnit until signed by the
Building official or his/her Deputy: and Fees are paid, and
FOR INSPECTION
receipt is acknowledged in space provided.
OFFIC S NAT R' D A/
(425)
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771-0220
E E BY DATE
EXT 1333
771-0221
ORIGINAL FILE - YELL04 ,�GECTOR
FAX
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FINAL I OJECT APPROVAL F01U
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MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Sign_
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FIN.r.AiPROJECT APPROVAL I ORM
TO:
DATE: —
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE.
PLEASESIGN
ENGINEERING DIVISION DATE
PLWF SIGN
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PLEMESIGN
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PERMIT#. ADB _________pATE INSPECTED--LL
DESCRIPTION OF WORK TO BE INSPECTED LEY I
A field inspection was conducted to determine final compliance with approved plans. Final approval
denotes that there are no objections from the above signed Department to the release of
PERFORMANCE BONDS and the granting of:
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
a Copy of CONDITIONS given to owner/contractor by inspector
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FAIILED FINAL INSPECTION - OUTSTANDING ISSUES
o Copy of CORRECTION NOTICE given to owner/contractor by inspector
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Sign
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
Pier/Porch .................
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Retaining Wall ........... 0
Slab Insulation .......... 0
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PLUMBING:
Underground .............
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Rough -in ...................
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Commercial Final ...... C)
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HEATING: M
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Gas Test ....................
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Gas Piping ................. >
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Equipment .................
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Commercial Final .......
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EXTERIOR SHEATHING M M
NAILING .......................... 0 vi
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FRAMING ........................ Y C/)
FIRST FLOOR FRAMING ... Q C)
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INSULATION ................... --I
Floor Insulation .........
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Wall Insulation ........... z
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Ceiling Insulation ....... :C
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SHEETROCK NAILING ...
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SPECIAL INSPECTION ...
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MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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