20040105.pdfCITY OF E
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BMIT APPLICATION
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NAME
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STATE LICENSE NUMBER EXPIRATION DATE bCMHEC D26Y
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PROPERTY TAX ACC�UqNTARCEL NO JF
0_NEW
M RESIDENTIAL
1:1 ADDITION
91COMMERCIAL
E] REMODEL
E] MULTIFAMILY
REPAIR
13 GRADING CYDS
DEMOLISH
11 TANK
GARAGE
RETAINING WALL
1:1
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ROCKERY
(TYPE OF USE, BUSIN�qa OR ACTIYITY) EXPLJ�P..,
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ui NUMBER
NUMBER 0
'3 OF
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DWELLING
0 STORIES
UNITS
DESCRIBE WORK TO BE DONE
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PLUMBING/MECH
COMPLIANCE OR
CHANGE OF USE
15�_SIGN
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FENCE
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OTHER
EFIRE SPRINKLER
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CRITICAL
AREAS
NUMBER /PC7
HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK NO: VESTED DATE
4"1.1 __C11/117 / I
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: 180DAYS
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a. PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) '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
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF 'THIS PERMIT SHALL NOT HE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
L3 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.'
PERMITEXPIRES
USE PERMIT
ZONE NUMBER
JOB SUITE/APT#
ADDRESS
Z. /
PLAT NAME/SUBDIVISION NO.
LOT NO,
LID NO�
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
I ESCP Approved 13
RW Permit Required 11
street use Permit Roq'd 13
EXISTING - PROPOSED
Inspection Required E3
Sidewalk Required 13
REQUIRED DEDICATION- Fr
Underground
tring require 13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 13 NO IJ
REMARKS
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OWNERICONfRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
VARIANCE OR CU
SEPA REVIEW
COMPLETE EXEMPT
EXP I
LOT COVERAGE
ALLOWED PROPOSED
A/A
PARKING
REO'D I PROV , IDED
REMARKS
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SHORELINE OR ADBI
INSPECTION
BOND
,REQ'D
POSTED
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G3YES ONO
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SIGN AREA
HEIGHT
ALLOWED PROPOSED
ALLOWED PROPOSED
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REQUIRED SETBACKS (FT)
PROPOSED SETBACKS (Fr.)
FRONT SIDE REAR
FRONT URSIDE REAR
A/A
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LOT AREA
PLANNING REVIEWED BY
DATE
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CHECKEDBY JTY��Q S f R�U51r 10 N jeD�� OCCUPANT
COPN GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [] YES I LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108/1FINAL INSPECTION REO'D
VAL I I A-171�-
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 CONSTFILIC-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN vlotATION OF THE LABO A&qDE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S -COMPENSAT SURANCE AND RCW 18.27.
SIGNATU DATE SIGNED
_J_I,JdWNER 0 K, ��T)
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Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
CALL
FOR INSPECTION
(425)
771-0220
FEE Description FEE
State Surcharge
City Surcharge
-7 '-
Plan Chk. Deposit .14,4-2
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/tier Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
OFPF)ALS SIGI�ArURE DATE
W44AI),41)1�111;
ATTENTION tyk I I
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CEFITIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
04!02 PRESS HARD -YOU ARE MAKING 5 COPIES
BY i
ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD . ASSESSOR
GREEN - ACCOUNTING
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MEMO TO:
FROM:
PROJ
SITE
FINAL PROJECT APPROVAL FORM
TO:
D A T E:
PERMIT COORDINATOR, BUILDING DIVISION
FIRE DEPARTMENT DATE
PLME SIGN
ENGINEERING DIVISION DATE —
PLEASE SIGN
PLANNING DIVISION DATE
PERMIT # ADB# DATE INSPECTED �/f / /�
1 -? '41 1 / 1
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DESCRIPTION OF WORK TO BE INSPECTED
A field inspection was conducted to determine final compliance with approv laus- Final approval
denotes that there are no objections from the above signed Department to the release of
PERFORM NCE BONDS and the granting of:
V/GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
u Copy of CONDITIONS given to owner/contractor by inspector
1 .
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inspector
1 .
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Si
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
Pier/Porch .................
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Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
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Underground .............
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Rough -In ...................
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Commercial Final ......
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HEATING:
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GasTest ....................
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Gas Piping .................
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Equipment .................
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Commercial Final .......
EXTERIOR SHEATHING
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NAILING ..........................
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FRAMING ........................
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INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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