20040005.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNE
.U�AME/NAME OF BUSINESS
MAII-ING ADDRESS
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CITY ZIP TELEPHONE
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NAME
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USE
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ADDRESS
PLAT NAME/SUBDIVISION NO.
PERMIT EXPIRES
PERMIT
NLIMBER,-P&41�
LOT NO.
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
METER SIZE I LINE SIZE] NO. OF FIXTURES
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LID NO,
LID FEE S
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Sidowalk Required
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pRV REQUIRED
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REMARKS
OWNER/CONTRACIOR RESPONSIBLE FOR EROSION CON1 ROIJDRAINAGE
ADDRESS
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CITY ZIP
TELEPHONE
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NAME
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ENG�NEERING REVIEWED BY DATE
ADDRESS
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FIRE REVIEWED BY DATE
CITY ZIP I TEI.EPHONE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY
;ROPERTY TAX ACCOUNT PARCEL NO.
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NEW
RESIDENTIAL
I
ADDITION
COMMERCIAL
7-4
AREMODEL
MULTIFAMILY
1:1
REPAIR
GRADING CYDS
El
DEMOLISH
TANK
GARAGE
RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN
NUMBER NUMBER OF
OF DWELLING
STORIES UNITS
DESCRIBE WORK TO BE DONE
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0
PLUMBING / MECH
COMPLIANCE OR
OF USE
CHANGE
SIGN
oFENCE
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OTHER
SPRINKLER
EFIRE
]
FIRE ALARM
VARIANCE OR CU
SEPA REVIEW
COMPLETE I EXEMPT
EXP
LOT COVERAGE
ALLOWED PROPOSED
SHORELINE OR ADB# INSPECTION BOND
REO*D POSTED
T—SIGN AREA I OYES ONO IS HEIGHT
I ALLOWED . PROPOSED I ALLOWED , PROPOSED
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REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (FT.)
FRONT SIDE REAR FRONT LJR SIDE REAR
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PARKING I LOT AREA I PIANNING REVIEWED BY DATE (L
REO'D I PROVIDED
REMARKS
CHECKED BY ITYPE 0 NSTRUCTION I CO]2E OCCUPANTL/?
1 GROUP
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CRITICAL OCCUPANT
AREAS —on SPECIAL INSPECTION JAREA LOAD
NUMBER REQUIRED []
YES
REMARKS z
PROGRESS INSPECTIONS PER UBC 1108/FINAL INSPECTION REQ'D
M
VALUATION
HEAT SOURCE
GLALZING %
LOT SLOPE %
PLAN CHECK NO:
VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I=
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
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PERMIT APPLICATION: 180 DAYS
IL
PERMIT LIMIT: I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
En
'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
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IN INTERESr, AGREES 10 INDEMNIFY. DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OFWHATEVER NATURE. ARISING DIREcri-YoRINDIRECILY
X
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF I Fits PERMIT SHALT. NOT 13E
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0
NOR LIMIT IN ANY WAY THE Cl TYS ABIHTY 10 ENFORCE ANY ORDINANCE PROVISION.,
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION, THAT THE INFORMATION
GIVEN IS CORRECT, AND T14AT I AM THE OWNER, on THE DULY AUTHORIZED AGENT OF
THEOWNER 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
,,�[�URANCE AND RCW 18 27.
SIGN NER P/XGENf)
DATE SIGNED
11
Description
:Ilan Check
3uilding Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
BMBS (EV1T,,1tT0R VAILIC 0;r8)
PERMANIENTU AFFLKED
:-SIPHON DEVICE LNSTALLED.
FEE Description FEE
State Surcharge
city Surcharge
Base Fee
CALL
FOR INSPECTION
(425)
771-0220
NTIONk---' E)ff 1333
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. UBC SECTION 109
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAI
This application is not a permit until signed by the
Building Official or hisiber Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
OKFI��l LS SIG A USE DAI E
S7/
RFI.EASFD 13Y ZATE
0111GINAL FILE YE [.LOW -INSPECTOR
PINK-OWNEH GOLD-ASSESSOn
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
Pier/Porch ................. z
0
Retaining Wall ...........
0
Slab Insulation ..........
PLUMBING: =n-
Underground .............
M
Rough -In ................... M
0
0
Commercial Final ...... 0 C
-4 K
X M
HEATING: M Z
GasTest .................... C _Z
r-
Gas Piping .................
Cn
Equipment ................. 0 -n
Commercial Final .......
EXTERIOR SHEATHING
C/)
NAILING .......................... 0 r-
0 M
C cf)
FRAMING ........................ C/)
Q C.)
FIRST FLOOR FRAMING ... Z r-
_1
INSULATION ................... ;U
--I
Floor Insulation ......... M
>
z
Wall Insulation ...........
Ceiling Insulation ....... CD
z
SHEETROCK NAILING ... 0
1
SPECIAL INSPECTION ... 0
171
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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