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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNE"MEINAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP Z ITELEPHONE
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NAMEP
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ADDRESS
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PERMIT EXPIRES
USE PERMIT
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NUMBER
JOB SUITE/APT#
ADDRESS,!�g(
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PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.--J
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Ap'
AW Permit R*..q."-
EXISTING R@FrqSE
P
Street Use Permit Req'.
Inspection Required 13
REQUIRED DEDICATION-11elt
Sidewalk Required 13
underground
Ir—
Wiring required 0
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 13 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ADDRESS
M 4/ �7
CITY ZIP TELEPHONE
let .. - - I - -1 - -
1. 1 EXPIRATION DATE I CHECKED BY
ROPERTY TAX ACCOUNT PARCEL NO.
A,P 9M7 e_1 j2
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0 NEW
RESIDENTIAL
1:1 PLUMBING / MECH
0 ADDITION
OMMERCIAL
AC
COMPLIANCE OR
1:3 CHANGE OF USE
REMODEL
[] MULTIFAMILY
1:1 SIGN
0 REPAIR
[3 GRADING
CYDS
M FENCE
L_J ( _ X_FT)
DEMOLISH
[3 TANK
OTH12a�&
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oGARAGE
CARPORT
I RETAININGWALL
0 ROCKERY
FIRE SPRINKLER
1:3 FIRE ALARM
(TYPE QF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER NUMBER OF CRITICAL
OF DWELLING
AREAS
STORIES UNITS NUMBE
DESCRIBE WCAK TO BE DONE AIF
0
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HEAT SOURCE GLAZING % LOT SLOPE %
PLAN C ET
H VESTED DATE
THIS PERMIT AlUTHORI=S ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES. ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMITAPPLICATION: ISO DAYS
PERMIT UMIT! I YEAR * PROVIDED WORK 15 STARTED WITHIN 1180DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE. HEIRS. ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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 COMPENSATION INSURANCE AND RCW 18.27.
(OWNER DATE SIGNED
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I ENGINEERING REVIEWED BY
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ALLOWED PROPOSED
-ALLOWED PROPOSED
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REQUIRED SETBACKS (FE):
PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT L/RSIDE REAR
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PARKING
LOTAREA
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PLANNING REVIEWED, 13Y DATE
REO`O PROVIDED
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REMARKS
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CHECKED BY ITYPE.OF CONSTRUCTION cons OCCUPANT
1!iiL V GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [3 YES LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 1108/FINAL INSPECTION REGO
VALUATION
$ �6" ,
Description
...FEE
Plan Check
Building Permit
j AIS
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Description
State Surcharge
City Surcharge
FEE
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
7
Landscapelnsp.
Total Amt. Due
Recording Fee
Receipt #
APPLICATION APPROVAL
CALL
This application Is not a permit until signed by the
Building Olficial or his/her Deputy: and Fees are paid, and
FOR INSPECTION
receipt Is acknowledged In space provided.
d
OF IGNAj9RE DATE
(425)
771-0220
_�_AEL ED BY /DATE
ATTENTION M13 3
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL -FILE YELLOW.4SP/CTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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FINAL PROJECT APPROVAL FORM
To:
DATE:
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PERWT ADB# DATE HAPEC
DESCRIPTION OF WORK TO BE INSPECTED
A Zeld ins ection was conducted to determine final compliance with approved plans. Final approval
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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
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
"a Copy of CONDMONS given to owner/contractor by inspector
FAELED FINAL INSPECTION - OUTSTANDING ISSUES
a Copy of CORRECTION NOTICE given to owner/contractor by inspector
2.
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Si-
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing......................
I., ....................
Pier/Porch ................
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Retaining Wall ...........
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Slab insulation ...........
PLUMBING:
Underground .... ........
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Rough -in ...................
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Commercial Final ......
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HEATING:
GasTest ....................
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�dai Piping ........... ......
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Equipent . ...................
commercial Final
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EXTERIOR SHEATHING
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NAILING . .....................
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FRAMING .....................
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INSULATION . ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
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SHEETROCK NAILING ...
SPECIAL INSPECTION ...
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MISCELLANEOUS ..........
FINAL APPROVAL FOR TS
OCCUPANCY ..................
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PATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNE:ff,VME/NAME OF BUSINESS
MAILING ADDRESS
4-dynjt�4 (
CITY ZIP TELEPHONE
W
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_7 -6140,
-F&IrnoWr ozo 74
NAMEp
/110�0
ADDRESS
FTrj4 Ale
CI ZIP TELEPHONE
S;��40_ N q?104- 176&-604-IM-7
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ZIP TELEPHONE
'EXPI
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NEW
0 RESIDENTIAL
ADDIMIN
OMMERCIAL
AC
REMODEL
MULTIFAMILY
REPAIOC'
GRADING CYDS
DEM06SH
TANK
GARAGE
o RETAINING WALL
CARPORT
ROCKERY
(TWME 9F USE. BUSINESS OR ACTIV" EXPLAIN:
NUMBER
OF
STORIES
NUMBER OF..
DWELLING' N/V
UNITS"
TO BE DONE
.rf'
[PERMIT EXPIRES L2�41
USE PERMIT
ZONE '2e��
NUMBER C�
JOB
ADDRESS
12
SUITE/APT#
_,6�4_q
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.-4
LID'MrV—
PUBLIC RIGHT OF WN? PER OFFICIAL STREET MAP
TESCP Approved
RW Permit Required
EXISTING PR� S E
Street Use Permit Req-d
Inspection Required
Required
�D
REQUIRED DEDICATION— VVSldews*
Underground
Wiring required 13
METER SIZE
LINE SIZE
77
0. OF FIXTURES
PRV REQUIRED
1
YES13 NO C3 3
REMARKS z
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY
Lu
i4
" /' -� / 6A,-9 I ?_ t (d lo z__
VJAIANICE OR ItU
ORELINEORADB11 I
INSPECTION
RECI'D
13YES EKO
POSTED
1$ BOND
TIONDATE-1
CtWCKEDBY
SEPA REVIEW
COMPLETE EXEMPT
EXP) 2
SIGN AREA
ALLOWED 1,PROPOSED
IVA
HEIGHT
ALLOWED , PROPOAD
N4.
PLUMBING/MECH
COMPLIANCE OR
13 CHANGE OF USE
SIGN
FENCE
X Fr)
OTH!&�:�o
FIRE SPRINKLER
FIRE ALARM
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (Fr.)
FRONT SIDE REAR
PROPOSED SETBACKS (Fr.)
FRONT URSIDE REAR
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tic
PARKING
REQ`D PROVIDED
ly (, I I
LOT AREA
PLANNING REVIEWED BY DATE
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REMARKS
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_151 ) A"� %0 1
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CHECKEDBY
TYPE=,QF CONSTRUCTION
OCCUPANT
GROUP
CRITICAL
AREAS
MUM PIPWIA0112
SPECIAL INSPECTION JAREA
REQUIRED [] YES
OCCUPANT
LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REG
$
Description FEE Description
Plan Check State Surcharge
9 1161'6
FEE
HEAT SOURCE
GLAZNG %
I
LOT SLOPE %
Building Permit
INS
City Surcharge
6?w
PLAN C�EZO- VESTED DATE
Plumbing
40
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
Grading
1= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
2 DOMAIN JCURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
3 SEPARATE PERMISSION.
L_ — -_ I . I
PERMIT A4L�&106�14D4s-.
1116 PERMIT UMrP 1 YEAR - PROVIDEdWORK IS sTARTEDi WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
�Engi% Review
Engr. Inspection
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Review
Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTUY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
Fire Inspection
Receipt #
A97,y
Landscapelnsp.
I
Total Amt. Due
d15.5de
NOR UMIT IN ANY WAY -THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
zi
Recording Fee.
Receipt #
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 C17Y 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
CALL
FOR INSPECTION
APPLICATION APPROVAL
This application Is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
recolpt Is acknowledged In space provided.
WORKMEWS COMPENSATION INSURANCE AND RCW 18.27.
(425)
771-0220
EXT 1333
OFFICI�COIGNAJVRE DATE
K11 &,.2 _/
SIGNATO
DATE I NED
AS
`hELE ED BY /DATE
Alft4ETION
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL - FILE YELLOW - 4SPR/CTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK - OWNER GOLD - ASSI
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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