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DATE RECEIVED 0
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF 13USINESS
MAILING ADDRESS
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NAME
CITY
ZIP
'7(
TELEPHONE
11q
11 U1 b - 5� ( � _-
ZIP I TELEPHONE I CBL ;
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ADDRESS
P6
CITY ZIP
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,�TATE LI ENSE /I /,I)
I , L -A-.K ,
I RE, 150 P
PROPERTY TAX ACCOUNT PARCEL NO.
El
NEW
ADDITION
REMODEL
REPAIR
E]
DEMOLISH
GARAGE
CARPORT
(TYPE OF USE. I
TELEPHONE
L1410
rgj�FXPIRAT ON DATE
PLUMBING if MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCF
Fr)
�DR"-VLT, ER
hETAINING WALL PRINKLER
ROCKERY El FIRE ALARM
;TIVITY) EXPLAIN:
k�,Tw) eN` _f 4��)
NUMBER NUMBER OF CRITICAL
OF DWELLING 41 AREAS
STORIES UNITS NUMBER
DESCRIBE WORK TO BE DONE
HEAT SOURCE
RESIDENTIAL
COMMERCIAL
Iselmo`ULTIFAMILY
GRADING CYDS
TANK
GLAZING %
I
LOT SLOPE %
PLAN CHECK NO: VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN JCURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
M SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
jW PERMIT LIMIT: I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
IL SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
tu IN INTEREST, AGREES TO INDEMNIFY. DEFEND AND HOLD HARMLESS f HE CITY OF
_j
2 EDMONDS. WASHINGTON. ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND
cc ALI- CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECII-Y
cc
x FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT BE
0 DEEMED TO MODIF'� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
_j ]NANCE PROVISION"
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORD
USE
ZONEf"'m
JOB
ADDRESS
PLAT NAMEISUBDIVISION NO.
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 PF�,TIIE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKM
,W,.�ff2tATION INSURANCE AND RCW 16.27.
SP YXT R R AGENT) DATE SIGNED
PERMIT EXPIRES
PERMIT
N U M 13 E R
SUITE/APT#
LOT NO.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING - PROPOSED
REQUIRED DEDICATION- FT
_F�
METER SIZE LINE SIZE NO. OF FIXTURES
LID NO.
LID FEE $
TESCP Approved
HW Pound Required
Stroet Use Pounit Roq'd
Inspection Required
Sidnwalk Requited
Underground
Winng filqUired
PRV REQUIRED
YES [I NO El
REMARKS
OWNER/CONTRACIOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
REVIEWED
FIRE REVIEWED BY
VARIANCE OR CU
SEPA REVIEW
COMPLETE , EXEMPT
EXP
LOT COVERAGE
ALLOWED PROPOSED
PARKING
REO'D I PROVIDED
REMARKS
DATE
DATE
SHOFELINE OR ADB# I INSPECTION BOND
'0REQ'D POSTED
_ Q8 NO S
YES
GN An EA HEIGHT
0 LLO
TALLOWSEID . PR PO�SEDA WED , PROPOSED
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UIRED SETBACKS (FT) PROPOSED SESTBACKSEA(F_0 I
INT U DE R
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LOT AREA I PLANNING REVIEWED BY DATE (L
CHECKED BY 0 51hu IIUN
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ON AREA OCCUPANT�
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SPECIAL INSPECTION AREA 7
TI LOAD
REQUIRED S
!YES
REMARKS z
PROGRESS INSPECTIONS PER LIBC 108/FINAL INSPECTION REQ'D
133
&202621 - MIE6
Ito-OtOA
VALUATION 7—
$ 1 m"p,
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
FEE Description FEE
State Surcharge L/
City Surcharge 45—
Base Fee Kz3_
CALL
FOR INSPECTION
(425)
771-0220
V_r .4 12 13 11
APlan Chk. Deposit
Receipt N
Total Amt. Due
�t6 -�3
.-Receipt N - f2m
APPLICATION APPROVAL
This application is not a pormil until signed by the
Building Official or hisitier Deputy: and Fees are paid, and
receipt is acknowledged in space provided
!rF IA Sl ATURF AT'
'C
R El
FAS E Y JDAT
jl�rTENTION
'It IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEFN 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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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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