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DATE RECEIVED
C1W OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
NAME
CITY ZIP I TELEPHONE
NAME
PERMIT EXPIRES
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USE PERMIT
ZONE NUMBER
JOB SUITE 11r 'N I ft
ADDRESS
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PLAT NAME/SUBDIVISION NO. LOT NO. LID NO.
LID FEE
7E—SCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit ROquirod
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Street Use permit Raq-d
inspection Required
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EXISTING — PROPOSED
Sidewalk nartuired
13
REQUIRED DEDICATION— FT
Undefg(Ound
winng required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES NO C3
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROIJORAINAGE
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CBL.N PAINK FlU. 9L-NIOVN-� U11 Uf1
/ .9 4/1 ENGINEERING REVIEWED BY DATE
ADDRESS
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CITY
ZIP
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TELEPHONE
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STATE LICENSE NUMBER
EXPIRATION DATE
CHECKED BY
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PRO�,0UNT
PARCEL NU.
NEW
R"RESIDENTIAL
PLUMBING / MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING
CYDS
FENCE X
Fr,
E] DEMOLISH
R-_TANK
OTHER
GARAGE
CARPnRT
RETAININGWALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER RUMBER OF CRITICAL
OF DWELLING AREAS
STORIES UNITS NUMBER
DESCRIBE WORK TO BE DONE
HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK NO: 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
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFX 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 COMPENSATI �ANCE AND RCW 18.27.
rSf*\TURE (OWNER 0�1 GENTI� DATE SIGNED
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FIRE REVIEWED BY
VARIANCE OR CU
SEPA REVIEW
COMPLETE , EXEMPT
EXP
LOT COVERAGE
ALLOWED PROPOSED
DATE
�HORELINE OR ADB# INSPECTION BOND
REO'D POSTED
SIGN AREA I []YES ONO S HEIGHT
FALLOWED . PROPOSED I ALLOWED . PROPOSED
REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT)
FRONT SIDE REAR FRONT UR SIDE REAR
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PARKING LOT AREA I PLANNING REVIEWED BY DATE IL
REO'D I PROVIDED I
REMARKS
CHECKED BY I TYP� OF CONSTRUCTION JCJ OCCUPANT
122A/4�� `7 GRO �1, /
SPECIAL INSPECTION J'AREA OCCUPANT
REQUIRED [] YES LOAD
REMARKS z
[PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D —9
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
FEE Description FEE
State Surcharge
i /5 City Surcharge
CALL
FOR INSPECTION
(425)
771-0220
Plan Chk. Deposit
Receipt #
Total Amt. Due �j
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building 011icial or his/her Depvty: and Fees are paid, and
receipt is acknowledged in space provided.
:*S SIGNATURE DATE
Fa_7
A17ENTION tyt I
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
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
GREEN - ACCOUNTING
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M MORANDUM
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Date: 3/2/04
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To: Debbie Karber, Accounting Assistant
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From: Marie Harrison
Subject: REFUND
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Debbie, please prepare a refund check in the amount of $55. Please charge building permi t
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$15.00, engineering in spection $25.00 and city surcharge $15.00. Please mail the check to Tanks
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By Dallas, 19551 400'Place Ne, Lake Forest Park, WA 98155. This site is outside city
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jurisdiction I have enclosed a copy of our receipt #23653 for your records. Thank you.
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Sincerely,
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AMan q%ie�n,�- tso "Jr
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Development Services Division Director's Signature
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City of Edmonds CQ Community Services
RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
Pier/Porch .................
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Retaining Wall ........... 0
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Slab Insulation ..........
PLUMBING:
Underground .............
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Rough -In ...................
1= 0
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Commercial Final ...... 0
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HEATING: K
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Gas Test ....................
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Gas Piping ................. F_ —4
Equipment .................
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Commercial Final ....... -n
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EXTERIOR SHEATHING
NAILING .......................... 0 F)
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FRAMING ........................ C: CD
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FIRST FLOOR FRAMING ... M 0
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INSULATION ...................
Floor Insulation .........
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Wall Insulation ........... z
Ceiling Insulation .......
SHEETROCK NAILING ... z
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SPECIAL INSPECTION ... 3
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MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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