20040195.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
67A<'-'Y
MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
ADDRESS
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CITY ZIP
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NAME
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ADDRESS
CITY ZIP
STATE LICENSE NUMBER
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TELEPHONE
7z-121. �1:511q
CBL 4
TELEPHONE
EXPIRATION DATE I CHECKED BY
21 PROPERTY TAX ACCOUNT PARCEL NO.
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31 00,,57�rOP000100700
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NEW
P,
RESIDENTIAL
PLUMBING / MECH
ADDITI ON
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADV CYDS
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FENCE X FT
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DEMOLISH
1:1
TANK
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OTHER
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GARAGE
CARPORT
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RETAINING WALL
ROCKERY
11
FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE. BUSINESS OR ACTIVITY) EXPLAIN:
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OF To ELLING AREAS
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0 STORIES U I NUMBER
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DESCRIBE WORK TO BE DONE
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ADDRESS
PLAT NAME/SUBDIVISION NO
PERMIT EXPIRES
PERMIT
NUMBER
SUITE/APT#
LOT NO. LID NO.
LID FEE $
TESCP Apptovld
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Polind 1`10(lulf0d [3
situal use permit Rocl,d 0
EXISTING — PROPOSED
inspection Required
1133
Sidewalk paquired
REQUIRED DEDICATION FT
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Wiringf0clUlfed
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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YES E3 NO 0
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DAT
VARIANCE OR CU HORELINEORADB# I INSPECTION I BOND
REO'D POSTED
OYES ��Ko I S
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE I EXEMPT ALLOWED PROPOSED ALLOWED. PROPOSED
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LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (FT)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SID.E JWwkF--
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PARKING LOT AREA PLANNING REVIEWED B D E.
REO'D I PROVIDED
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SPECIAL INSPECTION
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REMARKS
P p ROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
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HEAT SOURCE GLAZING % LOT SLOPE %
45914— 1
PLAN CHECZ: _� _12 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.
ir
LU PERMIT APPLICATION: IBODAYS
IL 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
M 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 MODIFX WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
2 NOR LIMITIN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
k I HE
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
IV
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HE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TjTION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
0
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IN VIOLATIO� OF THVLA13OR CODE OF THE STATE OF WASHINGTON RELATING TO
Won
WORKMEN) �OMPEYSATION INSURANCE AND RCW 18.27.
G ATU (00 �RA G E N T) DATE SIGNED
VALUATION
01
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
__111.71
City Surcharge
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
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Fire Inspection
Receipt #
LandscapeInsp.
Total Amt. Due
Recording Fee
Receipt #
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APPLICATION APPROVAL
CALL
This application is not a permit until signed by the
FOR INSPECTION
Building Official or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
OFFICIALS SIGNATURE DATE
42
771-0220
AS VY
DATE
A7 ON E)ff 1333 "1
IT I /N FUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A SIA PECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
04102 PRESS HARD -YOU ARE MAKING 5 COPIES
ORIGINAL - FILE YELLOW - INS4CTI!
PINK - OWNER GOLD - ASSESSOR
GREEN -ACCOUNTING
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APPROVED BY PLANNINIS
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BY ENGINEERINP
Date:
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CITYCOPY
FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASE SIGN
ENGINEERING DIVISION DATE—&/,z
LEASE SIGN
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PLANNING DIVISION DATE' i
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PERMIT 9 B# DATE INSPECTED 0 C:
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A field inspection was conducted to determine final compliance with approved plans. Final approval
denotes that there are no objections from the above signed Department to the release of
PERFORMANCE BONDS and the granting of:
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
o Copy of CONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
a Copy of CORRECTION NOTICE given to owner/contractor by inspector
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 ...................... VVIQ�
Wall..........................
Pier/Porch .................
Retaining Wall ........... z
0
Slab Insulation ..........
PLUMBING:
Underground .............
Rough -in ...................
M
C
Commercial Final ...... M
0
0
0
HEATING:
M
Gas Test .................... M
z
Gas Piping .................
> z
Equipment .................
Commercial Final ....... 0 -n
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EXTERIOR SHEATHING =
NAILING .......................... M M
FRAMING ........................ 0
0 M
FIRST FLOOR FRAMING ... C (1)
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INSULATION ................... Z r-
Floor Insulation .........
Wall Insulatio n ........... x
z
Ceiling Insulation .......
SHEETROCK NAILING ... vv\3 C4- Cn
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SPECIAL INSPECTION 0
0
M
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY .................. z"
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