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[DATE RECEIVE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING - PROPOSED
LID NO.
LID FEE $
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REQUIRED DEDICATION- FT Undeiground
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METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROWDRAIN
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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.
Lu PERMIT APPLICATION: 180 DAYS
CL PERMIT LIMIT: I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
(n 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESO S
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ul IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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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
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
01 NOR LIMIT IN ANY WAY THE CITY's ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
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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 LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION IMSURANCE AND RCW 18,27.
TURE (OWNER OR GENT) )
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1?71T,1,//Ir,2 eoAjor7 DATE SIGN, - 0 Lj
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
FEE
Description
FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due 5,
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Receipt # , / . , I
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
OFFICLALS41GNATURE DATE
ATTENTION EXT 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL L
A FINAL INSPECTION 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 COPIES
ORIGINAL - FILE) YELLOW - INSPECTOR
PINK -OWNER GOLD -ASSESSOR
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TLSCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required
Street U%o Permit Rect'd
EXIST114C - PROPOSED
inspection Required
Sidewalk Required
REQUIRED DEDICATION- FT
Underground
Ming required
METER SIZE
LINE SIZE
NO, OF FIXTURES
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PRV REQUIRED
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YES 0 NO 1:1
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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PARKING LOT AREA I PLANNING REVIEWED BY DATE
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Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE %
Building Permit city Surcharge
HECK NO: VESTED DATE Plumbing Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
PERMIT APPLICATION: 180 DAYS
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PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
V) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
M 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
DEEMED TO MODIFX WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapeinsp. Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION." '9
Recording Fee Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLI ATION 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 011icial 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 COMPENSATIO�tjkNSURANCE AND RCW 10.27.
OFFICIALS_SIGNATURE DATE,
SIGNATURE (OWNER OR A . GENT) DAT; SIGNED (425)
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-BY DATE
If'; 771-0220 RiELEASI�13 Z
ATTENTION EXT 1333 14
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IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL j
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINAL -FILE YELLOW - INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 PINK-OWNEFI GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch .................
Retaining Wall ...........
Slab Insulation ..........
0
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PLUMBING:
Underground .............
Rough -in ................... M
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Commercial Final ...... 0
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HEATING: -4
3: rn
Gas Test .................... M Z
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Gas Piping ................. >
Equipment .................
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Commercial Final .......
EXTERIOR SHEATHING
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NAILING..........................
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FRAMING ........................ 0 ITI
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FIRST FLOOR FRAMING... Cn
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INSULATION ................... -A
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Floor Insulation ......... __,I
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Wall Insulation ........... >
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Ceiling Insulation .......
SHEETROCK NAILING ... z
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SPECIAL INSPECTION ... --I
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MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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