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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
CITY ZIP TELEPHONE
NAME
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ADDRESS
CITY ZIP 1TELEPHONE
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PERMIT EXPIRES
USE PERMIT
ZONE
NUMBER
JOB SUITWAI'l N
ADDRESS C-1
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PLAT NAME/SUBDIVISION NO� LOT NO. LID NO.
LID FEE $
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP j1W pannn Roq,ii,od
Stine, use permit ROq'd
EXISTING - PROPOSED inspection pecluifod
Sidewalk Required
REQUIRED DEDICATION UndargfWnd
FT Winna joitlitrod
METER SIZE NO. OF FIXTURES PRV REQUIRED
YES NO C3
REMARKS
OWNEWCONIRACTOR RESPONSIBLE FOR EROSION CONTROUDRAINAGE
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ENGINEERING REVIEWED BY
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FIRE REVIEWED BY
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CITY ZIP
TELEPHONE
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VARIANCE OR CU �WOfIELINE OB ADB# I INSPECTION BOND D
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RE POSTED
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STATE LICENSE NUMBER RA1 ION DATE
CHECKED BY
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SEPA REVIEW SIGN AREA HEIGHT
COMPLETE EXEMPT ALLOWED PROPOSED ALL;OWED PROPOSED
PROPERTY TAX ACCOUNT� PARCEL NO.
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EXP
LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SET13ACKS (FL)
UR SIDE REAR
NEW RESIDENTIAL PLUMBING MECH
ALLOWED PROPOSED FRONT SIDE REAR FRONT
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COMMERCIAL COMPLIANCE OR
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ADDITION CHANGE OF USE
PLAN&= REVIEWED BY DATE
PARKIN LOT AREA
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REMODEL MULTIFAMILY J 3IGN
IOVIDED
REO' PROVIDED J�
GRADING FENCE
REPAIR CYDS ( x FT)
REMARKS
DEMOLISH TANK OTHER
GARAGE RETAINING WALL FIRE SPRINKLER
El ALARM
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MPE OF USE. BUSINESS OR ACTIVITY) EXPLAIN:
CHECKED BY
OCCUPANT
GROUP
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NUMBER
NUMBER OF
DWELLING
SPECIAL INSPECTION
OCCUPANT
LOAD
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OF '5,
STORIES
UNITS
REQUIRED YES
JAREA
DESCRIBE WORK TO BE DONE
REMARKS
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PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
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LUATION
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Description
FEE
Description
FEE
Plan Check
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State Surcharge
HEAT SOURCE
GLAZING %
LOT SLOPE %
Building Perm
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City Surcharge
Plumbing
Base Fee
PLAN CH NO: VESTED DATE
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Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: 180 DAYS
LU
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PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 100 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Fire Review
Plan Chk. Deposit
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'APPLICANI ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
Fire Inspection
Receipt
in
to
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IN INTERES1 AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS. tk�SHINGTON, ITS OFFICIALS. EMPLOYEES. AND AGENT S FROM ANY AND
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTIY OR INDIRECTLY
ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
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Total Amt. Due
EEMED 0 MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
Recording Fee
Receipt #
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I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
GIVEN IS CORRECT. AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF This application is not a permit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL Building Official or his/her Deputy: and Fees are paid, and
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LA13OR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S Cgk4P. I ENSATION INSURANCE AND RCW IB.27. O� 0 fALS SIGNATURE DATE
A71= SIGNED (4251 _26 . /' '' . . ..I _/
SIGNATURE CWNEP OR/AGENT) I " .->
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V'p - t - - -1 771-0220 �RELEAS
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ATTENTION Off 133a.�_.�
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
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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OnIGINAL-FILE YELLOW -INS ECTC
PINK -OWNER GOLD -ASSESSOR
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TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASESIGN
01 _ci " I I 11
�kENGINEERING DIVISION DATE
PLEASE SIGN
PLANNING DIVISION DATE
PLEASE SIGN
PROJECT
SITE ADDRESS- sk sw
PERMIT # ADB#__________PATE INSPECTED
DESCRIPTION OF WORK TO BE INSPECTED
A field inspection was conducted to determine 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:
-i-GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE given to owner/contractor by inpector
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2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1: temp:bldg: forms: ocaprvi 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing......................
Wall..........................
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Pier/Porch ................. 0
11
0
Retaining Wall ........... M
Slab Insulation ..........
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PLUMBING:
M
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Underground ............. M 0
0
—4
0
Rough -In ................... 0
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Commercial Final ...... M
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HEATING: C
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Gas Test .......... ......... r 3:
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Gas Piping .................. 0 -n
Equipment ................. —4
3:
M 171
Commercial Final .......
0
0
EXTERIOR SHEATHING 0 M
C CD
NAILING .......................... 90)
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0
FRAMING........................ Z
FIRST FLOOR FRAMING ...
INSULATION ................... :E
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Floor Insulation ......... z
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Wall Insulation ...........
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Ceiling Insulation ....... 0
SHEETROCK NAILING ... 0
M
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................