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DATE RECEIVED
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CITY OF EDMONDS ZONE
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEMAME OF BUSINESS
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MAILING ADDRESS
CITY
NAME
CITY
NAME
ADDRESS
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CITY
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STATE LICENSE NUMBER
PERMIT EXPIRES
PERMIT
NUMBER ZKTII-�
JOB
ADDRESS
PLAT NAME/SUBDIVISION NO. LO"T'NO.
4r. fAt'� PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
ZIP TELEPHONE EXISTING - PROPOSED
REQUIRED DEDICATION- FT
L/4Y-6 73/ 38 1 METER SIZE I LINE SIZE I NO. OF FIXTURES
ZIP I TELEPHONE
ZIP TELEPHONE
EXPIRATION DATE
L.4f) k0S,90603 671-:5-Jo-5-
CBL N
A
"ROPERTY TAX ACCOUNT PARCEL NO.
1-1.
60 4-?1 / 4.
1:1
NEW
,2---RESIDENTIAL
ADDITION
COMMERCIAL
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
1:1
DEMOLISH
D-1-ANK
GARAGE
CARPORT
o RETAININGWALL
ROCKERY
(TYPE OF USE. BUSINESS OR XTIVITY) JEXPI_AtN,�
NUMBER NUMBER OF
OF DWELLING
Ito STORIES UNITS
SUITE/Al?.T#
LID NO.
LID FEE $
TESCP Approved
13
E3
RW Permit Required
Street Use permit Req'd
[3
inspection Required
Sidnwalk Required
Underground
13
Wiring required _
PRV REQUIRED
YES 0 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
V 1
1 ENGINEERING REVIEWED BY DATE
PLUMBING / MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
( X FT)
OTHER
FIRE SPRINKLER
FIRE ALARM
CRITICAL
AREAS
NUMBER6:;-/7(
FIRE REVIEWED BY DATE
VARIANCE OR cu SHORELIINE 06R ADB# INSPECTION BOND
REO'D POSTED
OYES ONO IS
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE , EXEMPT ALLOWED , PROPOSED ALLOWED PROPOSED
EXP L__
LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED f , F hff;�' VA REAR FRONT UR SIDE REAR
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PARKINdI0,-.1 t6t rG Z514W(D DATE
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"ARE
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REMARKS
CHECKED BY TYPE C NSTRL�TION OCCUPANT
-Z�ROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [:] YES LOAD
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REMARKS a
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D 1 'F3
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HEAT SOURCE I GLAZING %
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
J SEPARATE PERMISSION.
Lu PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
V) OAPPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
2 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 BE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
3 0 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
WC)RKMFN'S COMPENSATK)N,W�URANCE AND RCW 18.27.
E _NT) DATE SIGNED
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
x
L�)
City Surcharge
Plumbing
Base Fee
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt H
Landscapelnsp.
Total Amt. Due
Recording Fee
Receipt #
CALL
FOR INSPECTION
(425)
771-0220
APPLICATION APPROVAL
j 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.
OFFICIALS SIGtjATURE D�TE
V'1'444-
RELtASED BY 1% /1DATE
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- ORIGINAL - FILE YELLOW, INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK - OWNER GOLD - ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: IRE DEPARTMENT DAT
PLEASE SIGN
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ENGINEERING DIVISION DATE
PLEASESIGN
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FLWESIGN PLANNING DIVISION DATE =i
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PROJECT 1)..3 7- OM
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PERMIT —DATE INSP 0 -1
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DESCRIPTION OF WORK TO BE INSPECTED_L) S_.7' LLL2--,,L,.oL1A-L,
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
u Copy of CONDITIONS given to owner/contractor by inspector
1 .
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
o 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 ...........
0
Slab Insulation ..........
PLUMBING*
Underground .............
0 M
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0
Rough -In ................... ITI
0
-40
Commercial Final ...... 0 C
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X M
HEATING: M Z
Gas Test .................... —Z
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Gas Piping .................
Equipment ................. 0 -n
Commercial Final .......
M M
EXTERIOR SHEATHING 0
NAILING.......................... 0
0 M
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FRAMING........................
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FIRST FLOOR FRAMING ... --I
INSULATION ................... ;U
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Floor Insulation ......... ------------ a:
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Wall Insulation ...........
Ceiling Insulation ....... CD
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SHEETROCK NAILING ... 0
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SPECIAL INSPECTION ... ITI
MISCELLANEOUS ..........
FINAL APPROVAL iQ6EL
...............
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