20040449.pdfW
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DATE RECEIVED
12
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY ITEIEPHONE
EDMOlva) 775 D-z
NAME
I CITY
ZIP
TELEPHONE
NAME BL 4'
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AD ESS
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CITY ZIP TELEPHONE
-S 91KM, 1 IMP- ov
STATE LICENSE NUMBER EXPIRATION DATE ED BY
UE LI 7
PROPERTY TAX ACC
-7
LINT PARC NO.
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NEW
A_
RESIDENTIAL
ADDITION
COMMERCIAL
REMODEL
MULTIFAMILY
E] REPAIR
GRADING CYDS
DEMOLISH
TANK
GARAGE
RETAINING WALL
ROCKERY
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CARPORT_
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(TYPE USE BUSINESS OR ACTIVITY) EXPLAIN:
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NUMBER
NU MBER OF
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DWELLING
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ol
STORIES
UNITS L
'r
—DESCRIBE W'ORKTO BE DONE
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CL-E7)W
HEAT SOURCE I GLAZING %
PLAN CHECK NO:
PLUMBING / MECH
COMPLIANCE OR
OF USE
CHANGE
SIGN
FENCE
FT
( X
OTHER
FIRE SPRINKLER
FIRE ALARM
—j
PERMIT EXPIRES
USE PERMIT
ZONE
NUMBER
SUITE/APT#
JOB
ADDRESS
ZDkl
7711-1 -5
PLAT NAMEISUBDIVISION NO LOT NO.
LID NO.
LID FEE
-fE—SCP Appro�ed
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW pef"Ilt Required
Usir Permit Ho(I'd
Street
in'spection Required
EXISTING — PROPOSED
SidnWalk Required
Undutground
REQUIRED DEDICATION� FT
W,flng(equirod
METER SIZE TURF
PRV REQUIRED
13
0
So 0
YES [I NO
REMARKS
OWNER/CONIRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
ENGINEERING REVIEWED
FIRE REVIEWED BY
DATE
DATE
VA IANCE OR cu SHORELINE 013 ADS# I INSPECTION BOND
REO'D POSTED
OYES ONO S
I = pl�-UT
SEPA REVIEW
COMPLETE , EXEMPT
EXP
LOT COVERAGE
ALLOWED PROPOSED
PARKING
REO'D I PROVIDED
REMARKS
CHECKED BY
SIG AREA F1
ALLOWED . PH POSED ALLOV. 1 1 PROPOSED
REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (FT.)
FRONT SIDE HEAR I FRONT UR SIDE REAR
LOT AREA I PLANNING REVIEWED BY
CRITICAL SPECIAL INSPE, — TZ�
AREAS REQUIRED OTION 11 �A
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NUMBER YES
DATE
OCCUPANT
GROUP
OCCUPANT
LOAD
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PROGRESS INSPECTIONS PER UBC 108/171NAL INSPECTI. ON REQ'D
A C c FIRE MARSHAL
LOT SLOPE %
VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
1= 13E DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS. MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
ui
CL PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
fA 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
U)
ui 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
cc ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
4
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF [HIS PERMIT SHALL NOT BE
a DEEMED TO MODIFN� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
-.1
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE Priuvialufm
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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 (3WNER ' I AGREE TO COMPLY WITH CIT-Y AND STATE LAWS REGULATING CONSTRUC-
TIONkAND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIVLATION OF Tli� LABOR CPDE OF THE STATE OF WASHINGTON RELATING TO
wr)nt&AFN,q.A0fARENEATION INIJURANCE AND RCW 16.27.
AGE
DATE SIGNED
6�2 - V — 0
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
! M I N PA F I L.1'.: 1 -1 t- IV 1,
FEE Description
State Surcharge
City Surcharge
Base Fee
CALL
FOR INSPECTION
(425)
771-0220
11 *1
u
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or hisilier Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
F6,�I�LA SIGNATURE D T
EASED BY
ATTENTION 1:A1 10
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 BEEN GRANTED. UBC SECTION 109
09103 PRESS HARD -YOU ARE MAKING 4 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK -OWNER GOLD -ASSESSOR
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FINAL PROJECT APPROVAL FORM %
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: z� FIRE DEPARTMENT DATE-6.:!
PLEASE SIGN
ENGINEERING DIVISION DATE
PLEASE SIGN
PLANNING DIVISION DATE
PI EA E SIGN
PROJECT L-PC u 3 A(
SITE ADDRESS -
PERMIT h2�L����ADB# DATE INSPECTED
DESCRIPTION OF WORK TO BE INSPECTED U,�`F) c74— CAY2'
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 :
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
F-1 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:fonns: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:.
GasTest ....................
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 ( ko
OCCUPANCY .................. 11L
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