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DATE RECEIVED 4
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
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CITY
NAME
I CITY
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CITY
STATE LICENSE NUMBER
ZIP TELEPHONE
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ZIP I TELEPHONE
CBL 0
ZIP n I YTELEP140NE
EXPIRATION DATE I CHECKED BY
PROPERTY jAX ACCO"T, ARCEL NO.
NEW
RESIDENTIAL
PLUMBING 1 MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
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MULTIFAMILY
SIGN
REPAIR
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FENCE
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GRADING
CYDS
DEMOLISH
El
TANK
1:1
OTHER
GARAGE
RETAINING WALL
1:1
FIRE SPRINKLER
ALARM
CARPORT
ROCKERY
FIRE
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
NUMBER NUMBER OF C RITICAL
OF DWEI , LING AREAS
UNITS NUMBER
STORIES I I
DESCRIBE WORK'TO BE DONE
HEAT SOURCE
GLAZING %
LOT SLOPE %
PLAN CHECK NO: )17) "li I 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
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CL PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
in 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
V)
!j IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS VHE CITY OF
M EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
cc ALI. CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIREC I IY OR INDIREc rLY
x 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
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.*
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 INSURANCE AND RCW 18,27.
DATE SIGNV
IG RE VWN 'AGENT)
f /) Lj PERMIT EXPIRES I-L-)y
USE PERMIT
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NUMBER,N
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S6!TE/APT#
ADDRESS
PLAT NAMEISUBDIVISION NO
LOT NO
LID NO.
LID FEE
IrsCP Approvorl
PUBLIC RIGHT OF 'NAY PER OFFICIAL STREET MAP
11W Parmit Racitirod
streel uso Permit Hert'd
EXISTING PROPOSED
Inspection Roct(wrid
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REQUIRFI) DEDICAI ION
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underground
Wiring roquirod
METER SIZE
NO OF FIXTURES
PRV REQUIRED
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REMARKS
OWNERYCONIRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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F-1 L I A I -
NEERING REVIEWED
REVIEWED 13Y
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REMARKS
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PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D F5
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ATTENT!9N I \\
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCfqRE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A"QERTIFl-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
09iO3 PRESS HARD -YOU AF
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CHECKED BY I TYPE QF�COUSTRUI
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee. -
CALL
FOR INSPECTION
(425)
771-0220
EXT 1333
FEE
Description
State Surcharge
City Surcharge
Base Fee
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a pennit until signed by the
Building 011icial or hisitier Deputy, and Fees are paid, and
receipt is acknowledged in space provided
9,�'ALS SipplilTURE DATE
/7
21 EASED BY,' DATH
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PINK - OWNER - GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASE SIGN
ENGINEERING DIVISION DATE
"Pel:ASL AGN
PLANNING DIVISION DATE
PLEASESIGN
PROJECT
SITE ADDRESS- 21300 0
PERMIT# ADB# DATE INSPECTED -25
104
DESCRIPTION OF WORK TO BE INSPECTED <�;l
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A field inspection was conducted to determine compliance with - approved plans. Final approval
denotes that there are no objections from the above signed Department to the release of
PERFORMANCE BONDS and the granting of:
/1)( GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
FAMED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
3.
RE -INSPECTED OUTSTANDING ISS UES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:fomis:ocaprv1 3/25/04
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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 ...
MISCELLANEOU5 .......... D4_
FINAL APPROVAL F08
OCCUPANCY .................
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