20040335.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY TTELEPHONE...
NAME
ADDRESS
CITY
NAME
ADDRESS
ZIP
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TELEPHONE
CBL #
CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE CACKED BY
-2� 3 - 2 73-
PROPERTY TAX. ACCOUNT PARCEL NO
13
NEW
1:1
ADDITION
1:1
REMODEL
9
REPAIR
El
DEMOLISH
EGARAGE
l
CARPORT
(TYPE OF USE, I
RESIDENTIAL
COMMERCIAL
MULTIFAMILY
GRADING
CYDS
TANK
RETAINING WALL
ROCKERY
OR ACTIVITY) EXPLAIN:
L)
NUMBER OF
OF DWELLING
I UNITS
ul UM13ER
to STORIES
7
DESCRIBE WORK TO BE DONE
HEAT SOURCE
PLAN CHECK NO:
GLAZING %
PLUMBING / MECH
El
COMPLIANCE OR
CHANGE OF USE
r_1
SIGN
oFENCE
( X FT,
OTHER
FIRE SPRINKLER
FIRE ALARM
CRITICAL
AREAS
NUMBER li
LOT SLOPE %
VESTED DATE
PERMIT EXPIRES
USE PERM
ZONE
N U M B E R
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JOB
ADDRESS
4`21�1_N_
e4u,
SUITE/APT#
7 5 /d
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
TESCP Approved 5
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
nw Permit Required 13
Street Use Permit Roq'd [3
EXISTING - PROPOSED
inspection Required 13
Sidewalk Required C3
REQUIRED DEDICATION-
FT
Underground
wiring required [3
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 0 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
NEERING
FIRE REVIEWED BY
D BY
FIT&O
DATE
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W
VARIANCE OR CU
SHORELINE OR ADB#
INSPECTION
BOND
REO'D
I
POSTED
I
OYES ONO
s
SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP I
,
I
LOT COVERAGE
REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LJR SIDE REAR
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PARKING
LOT AREA
PLANNING REVIEWED BY DATE
REO'D I PROVIDED
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REMARKS //
CHECKED BY ITYPE OF CON4TR4CTION copg OCCUPANT
GROUP
SPECIAL. INSPECTION JAREA OCCUPANT
REQUIRED [] YES LOAD
REMARKS z
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D Ei
A A --M M
VALUATION
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Description
Plan Check
Building Permit
Plumbing
Mechanical
FEE Description FEE
State Surcharge
/�t,q City Surcharge /"T
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
2 Grading
3 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION. Engr. Revie
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESCiRS Fire Review Plan Chk. Deposit
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS, WASHINGTON, ITS OFFICIALS. EMPLOYEES. AND AGENTS FROM ANY AND Fire Inspection Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE Landscapelnsp. Total Amt. Due
DEEMED TO MO DIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
OT01 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.* Receipt P
Recording Fee
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APP ION APPROVAL
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- CALL This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/her Deputy: and Fees are paid, and
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
ZFFI IGNAT DATE
IGNATURE (OWNER 0 AGENT),/ I DATE SIGNED (425)
P-1
e
6 771-0220
REL SED BY 6ATE
ATTENTION EXT 1333 �z
BUILDING OR STRUCTURE UNTIL
IT IS UNLAWFUL TO USE OR OCCUPY A
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL - FILE YELLOW - INSOECTOR/
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK - OWNER GOLD - ASSESSOR
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES GREEN - ACCOUNTING
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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:
GasTest ....................
Gas Piping .................
Equipment .................
Commercial Final .......
EXTERIOR SHEATHING _Svi J-- /,4,_OL�
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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