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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWIER NAME/V�ME OF BUS,��!S
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NAME
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ZIP
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TELEPHONE
ADDRESS
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STATE jLCENSE NUMBER PIRATION OPT
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NEW
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RESIDENTIAL
ADDITION
�,!CCOMMERCIAL
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
EiGARAGE
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RETAINING WALL
CARPORT
ROCKERY
(TYPE OF USE, BUS"EPSjq� ACTIVn E.,XPLPI
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NUMBER
NUM�B`EqOF
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OF
DWELLING
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STORIES
UNITS
DESCRIBE WORK TO BE DONE
LA,
HEAT SOURCE I GLAZING %
PLAN CHECK NO:
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USE
ZONE
JOB
ADDRESS
PLAT NAME,SUBDIVISION NO
PERMIT EXPIRES
PERMIT
NUMBER
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED--
f /11�
REQUIRE[) DEDICATION— FT
METER SIZE LINE SIZE NO. OF FIXTURES
SUITE/APT#
LID NO.
LID FEE $
TESCP Approved
fiW Permit Required
Street Use Permit Roq'd
Inspection Required
Sidewalk Required
Underground
Wiring required
PRV REQUIRED
YES 13 NO 0
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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1 —1 �s
ENGINEERING REVIEWED BY
DATE
SUL)
FIRE REVIEWED BY
DATE
VARIANCE OR CLI
SHORELINE OR ADIII
I INSPECTION
REO'D
EIYES ONO
BOND
POSTED
S
E
CH CKEF%Y
SEPA REVIEW
COMPLETE EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
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EXP
LOT COVERAGE
REQUIRED SETBACKS (FT)
PROPOSED SETBACKS (FT)
PLUM13ING if MECH
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT L/R SIDE REAR
COMPLIANCE OR
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CHANGE OF USE
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PARKING
LOT AREA
PLANNING REVIEWED BY DATE
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SIGN
REQ'D PROVIDED
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REMARKS
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CRITICAL
AREAS
NUMBER
LOT SLOPE %
VESTED DATE
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J 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.
cc PERMIT APPLICATION: 180 DAYS
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IL PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
in 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE. HEIRS, ASSIGNS AND SUCCESORS
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LU IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
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4 ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
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_j DEEMED TO MODIFN� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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 LA13OR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMP-OSATION INSURANCE AND RCW 18,27.
SIGNATURE AGENT) DATE SIGNED
-\� X �, 1-t -1 / I L, 4 ) IL. to 1,4
CHECKED BY ITYPE
OCCUPANT - I
GROUP 8 /s
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [] YES LOAD
REMARKS z
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ1D Zi
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
5_0
City Surcharge
Plumbing
Base Fee
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt
Landscapeinsp.
Total Amt. Due
Recording Fee
Receipt #
CALL
FOR INSPECTION
(425)
771-0220
APPLICATION APPROVAL
This application is not a perinit until signed by the
Building Official or hisitier Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
OFFICIALS SIGNATURE DAT
NA.
AlEtf_ASE�4 BY �__7TE
ATTENTIP Ex 1 1333
N u
IT IS UNLA� u L�TO SE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
N
A FINAL INSP15CTI N 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 CO IIES
ORIGINAL - FILE YELLOW - INSPECTO
PINK - OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: Y YRE DEPARTMENT DATE_�— 2-
_447E.. S�
1ASESIGN
ENGINEERING DIVISION DATE—
PLEASCSIGN
PLANNING DIVISION DATE
PLEASESIGN
PROJECT�Vl�;)� �'. /?/ 0 -E (--/ �
SITE ADDRESS
PERMIT B# DATE INSPECTED_L:!��_(),��.
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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
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
1:1 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:tenip:b1dg:f6rms:ocaprv1 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing......................
Wall..........................
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Pier/Porch .................
0
Retaining Wall ...........
M
Slab Insulation ..........
PLUMBING:
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Underground .............
M
0
__10
Rough -In ...................
0 C
Commercial Final ...... -------
:E M
M Z
HEATING:
C:
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Gas Test ....................
—Gas Piping — ..............
0 -n
Equipment .................
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—1
Commercial Final .......
M M
0 Cn
EXTERIOR SHEATHING
0
0 M
NAILING ..........................
C Cn
FRAMING ........................
Q 0
Z
A
FIRST FLOOR FRAMING ...
INSULATION ...................
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Floor Insulation .........
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Wall Insulation ...........
Ceiling Insulation .......
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0
SHEETROCK NAILING ...
0
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SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................