20040408.pdfI`_
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DATE RECEIVED
USE
CITY OF EDMONDS ZONE
JOB
CONSTRUCTION PERMIT APPLICATION ADDRESS
OV!iy_QLNAME/NAME OF BUSINESS
1� PLAT NAME/SUBDIVISION NO,
h o r, -s -1
MAILING ADDRESS
A 1611�-
0 �510 d r)- -7 7 k
CITY ZIP TELEPHONE
� n
e�
NAME
I CITY ZIP [TELEPHONE I
ADDRESS
CITY ZIP TELEPHONE
STATE LICENSE NUMBER
PROPERTY TAX ACCOUNT PARCEL NO
NEW
RESIDENTIAL
ADDITION
COMMERCIAL
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
GARAGE
CARPORT
RETAINING WALL
ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY),,EXPLAIN:
CBL $1
DATE I CHECKED BY
1 6)(1,111
N4LUMBING I MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
( x FT)
OTHER
FIRE SPRINKLER
FIRE ALARM
UJI NUMBER NU ' 'ER 0 CRITICAL
U
OF TDWMLLING AREAS
WI
U NI I
0 STORIES NUMBER
D ESCRIBE WORK TO BE DONE %
4Lj KLV— YO I te -r-
q4d s"Ink N _ax-sils /7,^S
HEAT SOURCE
GLAZING %
LOT SLOPE %
PLAN CHECK NID* VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT 1 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
w IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
_j
2 EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
0
_j DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
2 NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
JPERMIT EXPIRES
PERMIT
NUMBER
SUITE/APT#
LOT NO LID NO
LID FEES
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING - PROPOSED
HEQUIRED DEDICATION� Fr
METER SIZE LINE SIZE NO. OF FIXTURES
T-15CP APPIO-011
Fjvv parmit rij)quired
St,001 Uso Pormil lloq'd
inspOct on floqjillod
s.dowail, Requif0d
Unzirittifound
W,,,,g requirod
PRV REQUIRED
YES 0 NO 13
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLJDRAINAGE
ENGINEERING
FIRE REVIEWED BY
VARIANCE OR CU
SEPA REVIEW
COMPLETE EXEMPT
EXP I
LOT COVERAGE
ALLOWED PROPOSED
DATE
DATE
SHORELINEORADB# I INSPECTION BOND
REO'D P U S IT EU WD
01YES ONO S
SIGN AREA HEIGHT
ALLOWED , PROPOSED ALLOWED I PROPOSED
uj
REQUIRED SETBACKS (FL) PROPOSED SETBACKS (Fr.)
FRONT SIDE REAR FRONT UR SIDE REAR
z
PARKING I LOT ED BY DATE
REQ�D I PROVIDED
REMARKS
CHECKED BY I TYPE OE
ROU
I V �Iv I 117" /r N
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [] YES LOAD
REMARKS z
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION I4t:kXW 9
FEE Description FEE
State Surcharge 1�6;
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt
I 'I"
APPLICATION APPRI_
I his application is not a permit until signed by the
Building Olficial or his/tier Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
OFFICIALS SIGNATURE
DATE
RELEA 8 --------
1. i -- I -, DATE
A17ENTION EXT 1333
V"
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL L
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 I OWNER GOLD - ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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 VIOLATIOp-OF--rHE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'TFgMPENPATION INSURANCE AND RCW 18,27.
G ATUR tOWNE ED
SI �'LIOR AGEN
)d I DATE SIGN
T!, 7�YZ
VALUATION
$
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr, Inspection
Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
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 ................. INA\
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 s,
OCCUPANCY ..................
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