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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILINU ADDRESS
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CITY
ZIP TELEPHONE
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NAME
ADDRE 3,S_
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CITY ZIP
NAME
ADDRESS
CITY ZIP
STATE LICENSE NUMBER
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PERMIT EXPIRES
USE C--PERMIT
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UMBER,, 0,_x
JOB to SUITE
ADDIIESS-� 7/-,- /(] I
PLAT NAME/SUBDIVISION NO.
LOT NO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
7ESCP Approved
RW Permit Required
Street Use Permit Roq'd
EXISTING PROPOSE
Inspection Required
Sidewalk Required
REQUIRED DEDICATION- FT
Undrugmund
Wiring required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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YES 13 NO 0
OWNEFIXONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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IIENGINEERING REVIEWED BY DATE
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11111 FIRE REVIEWED BY DATE
TELEPHONE
EXPIRATION DATE I CHECKED BY
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FRTY T? AccqUNT PARCEL NO.
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NEW
RESIDENTIAL
PLUMBING/MECH
ADDITION
OMMERCIAL
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COMPLIANCE OR
CHANGE OF USE
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MULTIFAMILY
r5<_IGN
REPAIR
GRADING
CYDS E]
FENCE
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DEMOLISH
TANK
OTHER
GARAGE
RETAINING WALL
FIRE SPRINKLER
CARPORT
ROCKERY
FIRE ALARM
(TYPE gqU§P, BUSINEjt3SN ACTIVITY) EXPLAIN
W NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
ci STORIES UNITS I NUMBER 474
DESCRIBE WORK TO BE DONE
3 2,
en A-;) e-
HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK NO: 1--�j ; I YESTED
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERAIT dOVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWAIXS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
W PERMIT APPLICATION: 180 DAYS
IL PERMIT LIMIT: I YEAR - PROVIDED WORK IS STARTED WITHIN iso DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Cn 'APPLICANT. ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
in
�j IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
4 ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECFLY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
DEEMED TO MODIF'� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.-
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VARIANCE OR CU
HORELINE OR ADBI
INSPECTION
BOND
REQ�Dl.
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POSTED
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OYES ANO
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SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED, PROPOSED
ALLQWED PROPOSED
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EXP
LOT COVERAGE
REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (FT)
NLLOWED PROPOSED
FRONT SIDE REAR
FRONT LJRSIDE REAR
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PARKING
REO'D I PROVIDED
LOT AREA
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REQUIRED [] YES
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REMARKS
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PR
PROGRESS INSPECTIONS PER UBC 108/IBC109/IRC109 FINAL INSPECTION REQ'D
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
FEE
Description
0
State Surcharge
City Surcharge
Base Fee
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt r70 ',�U
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 APPLICATION APPROVAL
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC- This application is not a permit until signed by the
TION; AND IN DOING THE WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED CALL Building Official or his/tier 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 COMPENSATION INSURANCE AND RCW 18.27. ----------
OFF! IALS SIG URE
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SIGNATURE (OWNEF1104� DATE SIG D
(425)
LEAS
'AfTENTION E)ff 133
ITIS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/IBC110/lRC110.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
By
DATE
ORIGINAL -FILE YELLOWIINSPEITC
PINK -OWNER GOLD -ASSESSOR
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TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM:
FIRE DEPARTMENT DATE
PLrASESIGN
DIVISION DATE
PLEASESIGN
—ENGINEERING
PLANNING DIVISION DATE
PLEASP SIGN
PROJECT
SITE ADDRESS-11 12, it 'UP1 sr
PERMIT ADB# DAT SPECTED '_71_2 7 leo-y
DESCRIPTION OF WORK TO BE INSPECTED
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:
Y_ _GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
I .
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 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:fbrms:ocaprv1 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
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Pier/Porch ................. 0
0
Retaining Wall ........... ITI
Slab Insulation ..........
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PLUMBING: Cl)
M
Underground ............. C
M 0
0
Rough -In ................... 0
0 C
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Commercial Final ...... x M
M Z
HEATING:
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Gas Test .................... —1
x
Gas Piping ................. 0)
0 -n
Equipment ................. -4
Commercial Final ....... M M
0
EXTERIOR SHEATHING 0
NAILING .......................... M
C C/)
Cn
FRAMING ........................ Q 0
Z
FIRST FLOOR FRAMING ...
INSULATION ...................
Floor Insulation ......... z
Wall Insulation ...........
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Ceiling Insulation ....... 0
SHEETROCK NAILING ... 0
171
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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