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CITY OF EDMONDS zo�(C?
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CONSTRUCTION PERMIT APPLICATION I
ADDRESS
OWNER NAME/NAME OF BUSINESS
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LAT N4MEISUBDIVISION NO.
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE BY
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NO.
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ADDITION
COMMERCIAL
o COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING
CYDS
FENCE
( X FT)
DEMOLISH
TANK
OTHER
GARAGE
CARPORT
RETAINING WALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS
OR ACTIVITY) EXPLAIN:
NUMBER
NUMBER OF
CRITICAL
OF
STORIES
DWELLING
UNITS
AREAS
NUMBER
DESCRIBE WORK TO 13E DONE
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HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK NO* VESTED DATE
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: 180 DAYS
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
V) 'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
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uj IN INTERES1, AGREES 10 INDEMNIFY, DEFEND AND IIOLD HARMLES 1HE CITY 01
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M EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGEN1S FROM ANY AND
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.t ALI- Cl AIMS FOR DAMAGES OF wi-iATEVER NAT URE, ARISING DIRECTLY OR INDIRECTLY
x FROM rHE ISSUANCE OF 411S PERMIT, ISSUANCE OF THIS PERMIT SHAI I. NOT 13E
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_j DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
L3 NOR LIMIT IN ANY WAY I HE CITY'S ABILITY 10 ENFORCE ANY ORDINANCE PROVISION -
PERMIT EXPIRES
PERMIT 4
NUMBER
Lot NO.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING - PROPOSED
REQUIRED DEDICATION- FT
METER SIZE I LINE SIZE I NO. (�F_fIXTURES
SUITE/APT#
I I / / ( , , / ,
LID NO.
LID FEE $
TESCP Approved 13
RW Permit Required 13
Strout Use Permit Roq'd 13
Inspection Required 13
Sidewalk Required 0
Underground
Wiring required 0
PRV REQUIRED
YES IJ NO A
REMARKS
OWN ER/CON TRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY
FIRE REVIEWED BY
E
DATE
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INSPECT160 N_�T
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POSTED
DYES ONO
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SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP
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LOT COVERAGE
REQUIRED SETBACKS (FTj
PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT UR SIDE REAR
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P %RKING
LOT AREA
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PLANNING REVIEWED BY DATE
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REO'D I PROVIDED
REMARKS
CHECKED BY ITYPE
CODE OCCUPANT
GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED 0 Y1 LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
Plumbing
Base Fee
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
I
Fire Inspection
Receipt tl
44- ("1
LandscapeInsp.
Recording Fee
Total Amt. Due
Receipt N
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 APPLICATION APPROVAL
THE OWNER. I AGREE 10 COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- I his application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF TIIE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATIgN INSURANCE AND RCW 18 27.
OFj-lqj4S SIGOAFJIRF DATE j
SIGNATURE (OWNER OR'J\�GENT)
DATE SIGNED
(425)
771-02 20
RFIFASrD
ATTENTION
EXT 1333
IT IS UNLAWFUL TO USE OR OCCUPY A
BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
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CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
09iO3
PRESS HARD -YOU ARE
MAKING 4 COPIES
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OF41GINAL ILE YELLOW JNSP
PINK-,O)N'ER GOLD -ASSESSOR
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch .................
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
..........
Rough -In ...................
Commercial Final ......
HEATING:
Gas Test ....................
Gas Piping .................
Equipment.................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST FLOOR FRAMING...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
. ............... V,
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