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CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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LW MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
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ADDRESS
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CITY ZIP ITELEPHONE
7W 0314
NAME CBL#
ADDRESS
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C ITY ZIP TELEPHONE
STATE LICENSE NUMBER
EXPIRATION DATE I CHECKED BY
PROPERTY TAX ACCOUNT PARCEL NO.
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NEW
RESIDENTIAL
PLUMBING / MECH
. ,ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
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MULTIFAMILY
SIGN
11 REPAIR
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FENCE
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OTHER
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CARPORT
Ei RETAININGWALL
ROCKERY
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FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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OF DWELLING AREAS
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1 DESCRIBE W RK TO BE DONE
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HEAT SOURCE LAZING % LOT SLOPE %
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PLAN CHECK NO; I I VESTED DATE
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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: ISO 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 INDEMNIFY, 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 CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION.0
P :L I I PERMIT EXPIRES
USE PERMIT
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PLAT NAME/SUBDIVISION NO, LOT NO, LID NO,
LID FEE S
Approved
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PUBLIC RIGIR OF WAY PER OFFICIAL STREET MAP F1 V
Stfee, Use permit Hoq'd
EXISTING Inspection sequired
-- PROPOSED Sldowllk Required
underground
REQUIRED DEDICATION FT
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METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
YE NO 13
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REMARKS
OWNEWCONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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REVIEWED BY
VARIANCE OR CU
SEPA REVIEW
COMPLETE EXEMPT
EXP I X
LOT COVERAGE
ALLOWED PROPOSED
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PARKING
REO'D I PROVIDED
REMARKS
BY ITYPE
DATE
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HORELINE OR ADB#T
INSPECTION
REO'D
—BOND
POSTED
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IS
SIGN AREA
HEIGHT
ALLOWED PROPOSED
ALLOWED PROPOSED
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REQUIRED SETBACKS (FT)
PROPOSED ETBACK
FRONT $IDE REAR
FRONT REAR
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LOT AREA
REVIEWED BY DATE
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SPECIAL INSPECTION JAREA
REQUIRED [] YES I
OCCUPANT
GROUP
OCCUPANT
LOAD
REMARKS
P50GRESS INSPECTIONS PER UBC 108/FlNAL INSPECTION REQ'D
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VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
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 CALL
IN VIOLATIOq OF THE LABOR, CODE PF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION
WORKMEN'S/)COM_PENSATION/4NSURArE AND RCW IB.27,
S G AT7U (O!7W� 01`1�91ENT]l DATE SIGNED
FEE
Description
State Surcharge
City Surcharge_
Base Fee
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FEE
7-7--
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building 011icial or his/her Deputy: and Fees are paid, and
receipt is acknowledged if' space Provided,
ICI -' IGr E DATE
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n�f!�fFD BY,
/ I DATE
All It: L UFM C:A 1 1%3%3%3 L. Lu
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
(425)
771-0220
I.
ORIGINAL - FILE
PINK - OWNER
GOLD - ASSESSOR
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ALL EXPOSED SURFACES TO
BE COVERED WITHIN 2 DAYS
APPHOVED AS NaFEU
BY EN
GINEERING
Q/ Date: 4-16)-04-
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APR - 12004
CITY COPY PERMIT COUNTER
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASE SIGN
Y-91e A/72,J(j'�l ENGINEERING DIVISION DATE_&�2
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PLAN1%flNG DIVISION DATE' F5
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PROJECT k /9-� /-1 =-n
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PERMIT ADB# DATE INSPECTED C15/1/� 4� lel-;4
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DESCRIPTION OF WORK TO BE INSPECTED 1< Opp
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
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 .................
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
Rough -In ...................
Commercial Final ......
HEATING -
Gas Test ....................
Gas Piping .................
Equipment .................
Commercial Final .......
EXTERIOR SHEATHING
NAILING..........................
FRAMING ........................
FIRST FLOOR FRAMING ...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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