20040306.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
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CITY TELEPHONE
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NAME
ADDRESS
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[PERMIT EXPIRES
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NUMBER
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PLAT NAME/SLIBDIVISION NO LOT NO. LID NO.
LID FFF S
Tl�SGP Approved
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
R�V pitfoin Rriq ... ed
Street use PO It Hoq'd
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EXISTING - PROPOSED
inspection ReZrad
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Sidewalk Requited
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REQUIRED DEDICATION- FT
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METER SIZE
LINE SIZE
NO, OF FIXTURES
PRV REQUIRED
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REMARKS
OWNER/CONTRAC1OR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
NAME CBLm
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CITY ZIP TELEPHONE
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VARIANCE OR CU SHORELINE OR ADBI INSPECTION BOND
STATE LICENSE NUMBER EXPI TION DATE CIIECKED BY REQ'D POSTED
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PROPEEkLTY TAX ACCO NT PARCEL NO. f f COMPLETE , EXEMPT ALLOWED , PROPOSED ALLOWED , PROPOSED
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LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (FT.)
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REMODEL MULTIFAMILY SIGN RECrD I PROVIDE61 M
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w NUMBER NUMBEIR OF CRITICAL
a OF DWELLING AREAS SPECIAL INSPECTION rAgEA OCCUPANT
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DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D z
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Clit i-z,( %le Description FEE Description FEE
HEAT SOURCE GLAZING % LOT SLOPE I% Plan Check State Surcharge
Building Permit City Surcharge
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PLAN CHECK NO: VESTED DATE Plumbing Base Fee
Mechanical
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 Grading
SEPARATE PERMISSION. Engr. Review
cc PERMIT APPLICATION: 180 DAYS
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PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Fire Review Plan Chk. Deposit
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
ILI IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS *THE CITY OF — -------
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2 EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
ALL CLAIMS FOR DAMAGES OFwHATEVER NAIURE, ARISING DIRECfIYORINDIREC1LY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF 1111S PERMIT SHALL NOT 13E
(31 DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapelnsp. Total Amt. Due
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0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
Recording Fee Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION, THAT THE INFORMATION
GIVEN IS CORRECT: AND THAT I AM THE OWNER. OR THE DULY AUTIIORIZED AGENT OF APPLICATION APPROVAL
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- CALL This application is not a perinit until signed by the
TION. AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Olficial or his/tier Deputy: and Fees are paid. and
IN VIOLATION OE_111E LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space Provided.
WORKMEN'S — PEN5A�ION INSURAN3"D RCW 18 27.
?"M :DVIAI ?SIGNATURE D T
[SIG7 E NER 0 GENT) DAI� 11 GNED
('425) A
771 ASED BY TE
0220
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
0903 PRESS HARD -YOU ARE MAKING 4 COPIES
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FINAL PRWECT APPROVAL FORM
(2p TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FIRE DEPARTMENT DATE 'C')
FROM:
PLEASE SIGN
ENGINEERING DIVISION DATE
PLEASESIGN
PLANNING DIVISION DATE
PLEASE SIGN
PROJECT_U_&�—/
SITEADDRESS 1(16(e
PERMIT LADB#______�DATE INSPECTED
DESCRIPTION OF WORK TO BE INSPECTED 0.%1—
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
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GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
El Copy of CONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
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 ..........................
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 ...
ANEOUS
..........
FINAL APPROVA� �O 7
OCCUPAN`CY_:: ................
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