20040392.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
QV)NER NAME/NA E OF BUSINESS
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MAILING ADDRESS
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NAME
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EXPIRATION DATE
STATE LICENSE NUMBER
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PROPERTY TAX A
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COUNT P CEL NO.
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NEW
RESIDENTIAL
PLUME31NO / MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING
CYDS
FENCE
( X FT,
DEMOLISH
TANK
OTHER
oGARAGE
RETAINING WALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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OF DWELLING AREAS
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PLANCHECKNO: VEST��
THIS PERMIT AUTHORIZES ONLY THE WORK NO\D. THIS P IT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. AN ONSTRU ION ON THE PUBLIC
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DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS JjS I ROLI/E, ETC.) WILL REQUIRE
SEPARATE PERMIS ON.
PERMIT APPLICATION: I a is
PERMIT LIMIT., 1 YEAR - PROVIDED WORK IS Sv. WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MOR FORMATION
*APPLICAN1. 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 OFWHATEVER NATUIIE,AIIISINGI)IRECFiYOHINDItIECTtY
FROM T14E ISSUANCE OF THIS PERMIT. ISSUANCE OF I HIS PERMIT SHAL I NOT 13E
OEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIRFMEN I OF ANY Ci TY ORDINANCE
NOR LIMIT IN ANY WAY THE CITY'S ABI1 11Y TO FNFORCF ANY ORDINANCE PROVISION "
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION, THAT THE INFORMATION
GIVEN is CORRECT, AND THAT I AM THE OWNER, 014 THE DUTY AUTHORIZED AGENT OF
THE OWNER. I AGREE To COMPLY WITH CITY AND STATE LAWS REGULATING CONSITILIC
TION. AND IN DOING IIAE WORK AUTHORIZED THEREBY. NO PERSON WILL 13L EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSAT,10N IN \ SURANCE AND RCW 18 27
SIGNATURE (OWNER 0 AGEN) DATE S17NED
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Pi AT NAME/SUBDIVISION NO LOT NO LID NO.
LID FEE $
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F31JBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
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RW Permit floquired E3
Street Use Porten Roq'd 0
EXISTING - PROPOSED
Inspection Required 0
Sidewalk Required 13
REQUIRED DEDICATION- FT
Underground
Wiring required E3
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
0
YES 11 NO 13
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REMARKS
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OWNER/CON TRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
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Description
OCCUPANT
GROUP
OCCUPANT
LOAD
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ECTIONS PER UBC 108/FINAL INSPECTION REO'D a
FEE Description FEE
State Surcharge
City Surcharge ti
7�
Base Fee
Plan Chk. Deposit
Receipt it
Total Amt. Due
Receipt #
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APPLICATION APPROVAL
I his application is not a permit until signed by the
Building Official or his/her DOPLAY: and Foes are paid, and
receipt is acknowledged III space provided.
OFFICIM S SIGNAI URE DATE
RIFT SF(?- Y A!
ATTENTION EXT 1333
LIE,
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL A, L ( I iI
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- OHIGINAL . FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK OWNER GOLD -ASSESSOR
09 03 PRESS HARD -YOU ARE MAKING 4 COPIES
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
CALL
FOR INSPECTION
(425)
771-0220
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
z
0
Pier/Porch .................
--I
0
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
0 M
C
Underground .............
M
0
__40
0
Rough -In ...................
C
Commercial Final ......
M
M Z
HEATING:
C
Gas Test ....................
3:
ch
Gas Piping .................
0 -n
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--I
Equipment .................
3:9
Commercial Final .......
0
0
EXTERIOR SHEATHING
0 1711
C Cn
NAILING ..........................
Q 0
FRAMING ........................
Z r-
FIRST FLOOR FRAMING ...
;U
--I
INSULATION ...................
:C
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Floor Insulation .........
--I
Wall Insulation ...........
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Ceiling Insulation .......
0
SHEETROCK NAILING ...
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SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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