20040344A.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNE�AMEINAME OF BUSINESS
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CITY ZIP TEL EPHONE
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NAME
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CITY
ZIP I TELEPHONE
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PERMIT EXPIRES
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PERMIT
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NUMBER
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ADDRESS
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PLAT NAME/SUBDIVTSION NO
LOT NO.
LID NO.
LID FEE $
tADREUSE
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
RW Paired Required
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EXISTING 13ROPOSED
Street Use Porritit Req'd
inspection Required
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Sidewalk Required
REQUIRED DEDICATION- FT
Underground
Wiringroquired
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ETER SIZE
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LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YE NO
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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NAME
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CITY ZIP
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TELEPHONE
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STATE LICENSE NUMBER EXPIYATIOY DATE
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PROPERTY TAX ACCOUNT PARCEL NO.
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GARAGE o RETAINING WALL FIRE SPRINKLER
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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OF DWELLING AREAS
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DESCRIBE WORK TO BE DONE
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ENGINEERING REVIEWED BY DATE
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VARIANCE OR CU
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INSPECTION I
BOND
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SEPA REVIEW
SIGN AREA
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ALLOWED PROPOSED
ALLOWED PROPOSED
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REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (Fr.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT L/R SIDE REAR
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LOT AREA
PLANNING REVIEWED BY DATE
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REO'D I PROVIDED
REMARKS
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GROUP
SPECIAL INSPECTION
OCCUPANT[
REQUIRED [] YES
JAREA
LOAD
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
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A tex VALUATION
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PLAN CHECK NO: I VESTED DATE
24 —1 S�L
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180DAYS
CIL 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
Lu IN INTEREST AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
_j EDMONDS, ik�SHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
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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 CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
21
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 AUTHORVED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WOHKMEN'S COMPENSATION INSURANtE AND RCW 18.27.
_-SIGN TLJRE WNER OR I AG r) " of DATE (G7
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Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt Jr �C'/
APPLICATION APPROVAL
This application is not a perpnit Until signed by tire
Building 011icial or his/tier Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
:EICWS SIGt4TURE DATE
RELEASED BY I DATIE
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-At -11 hN-f-IUM EA 1 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-FIL� YELLOW. INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK -OWNER GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
CALL
FOR INSPECTION
(425)
771-0220
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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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