20040022.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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NAME
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PERMIT EXPIRES
USE PERMIT
ION17 NUMBER,
JOB SUITE/APTff�
ADDRESS /c`/5;rj 7 1
PLAT NAMEISUBDIVISION NO
LOT Vb.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
IF.SGP App(rived
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EXISTING — PROPOSED
Inspection Firiquifed
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REQUIRE[) DEDICATION— FT
Undeig(ound
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METER SIZE
L114E SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 0 NO 13
REMARKS
OWNER/CONiRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
Oggnilym BY CITY INSPECTOR
CBL 4 J)W
AFFIDAVITS SHALL NOT
ENGINEERING REVIEWED BY BE ACCEPTED DATE
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STATE LICENSE NUMBER EXPIRATION DATE CHECKED BY
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PROPERTY TA2L ACCOUNT PARCEL NO.
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ADDITION
COMMERCIAL
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
oGARAGE
RETAINING WALL
CARPORT
ROCKERY
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NU
NUMBER OF
0
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DWELLING
UNITS
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DESCRIBE WORK TO BE DONE
HEAT SOURCE I GLAZING %
PLAN CHECK NO:
PLUMBING / MECH
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COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
( — X_
OTHER
FIRE SPRINKLER
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FIRE ALARM
FIRE REVIEWED BY
DATE
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HEIGHT
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ALLOWED PROPOSED
ALLOWED PROPOSED
EXP ,
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LOT COVERAGE
REQUIRED SETBACKS (FT)
PROPOSED SETBACKS (FT)
ALLOWED PROPOSED
FRONT SIDE REAR
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NUMBER REQUIRED [:] YES LOAD
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jPROUIRE55 INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
&
LOT SLOPE %
VESTED DATE
THIS PERMIT AUTHORIZES 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.
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANI, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARNU ESS THE ci ry OF
EDMONDS. WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NAT URE, ARISING DIREC FLY Oil INDIRFC HY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF IHIS PERMIT SHALL NOT 13E
DEEMED To MODIF'� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITY'S ABIL11Y 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 AGRI�E 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.
SIG�N)TURE (OWNER
XOAGENTI' DATE SIGNED
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VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building PerrTlit___
42 1/
City Surcharge
<5
Plumbing
Base Fee
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapelnsp.
Total Amt. Due
Recording Fee
Receipt # 55
CALL
FOR INSPECTION
(425)
771-0220
APPLICATION APPROVAL
I his application is not a perinit until signed by the
Building Official or his/her Deputy. and Fees are paid. and
receipt is acknowledged in space provided
0- IAI S SIG AIURF DATE
1
—11FIFASFD
BY DATE
AXTENTION 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
CHIGNAL -FILE YELL(DW- INSPECTOR
PINK -OWNER GOLD -ASSESSOR
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At
RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS ......................
FOUNDATION.
Footing'...* ..................
Wall ..........................
Pier/Porch .................
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Retaining Wall ...........
M
Slab Insulation ..........
PLUMBING:
Underground .............
M
C
M
Rough -In ...................
0
-40
0
Commercial Final ......
C:
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HEATING:
M z
Gas Test ....................
>
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Gas Piping .................
r-
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Equipment .................
0 _n
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Commercial Final .......
M ITI
EXTERIOR SHEATHING
00)
0
NAILING ..........................
0 M
FRAMING ........................
Q 0
Z
FIRST FLOOR FRAMING...
INSUkATION ...... I ......
:C
Floor Insulation ..........
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Wall Insulation ...........
Ceiling Insulation .......
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0
SHEETROCK NAILING ...
--I
0
SPECIAL INSPECTION ...
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MISCELLANEOUS ..........
FINAL APPROVAL FOR
0
OCCUPANCY ..................
000