20040545.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
CITY
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NAME
NAME
ADDRESS
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CITY
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STATE LICENSE NUMBER
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PROPERTY TAX ACCOUNT
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ZIP TELEPHONE
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PERMITEXPIRES
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SUITEIAPT#
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PLAT NAMEISUBDIVISION NO.
LOT NO.
L�D NO.
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UBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved U
RW Permit Required Q
Street Use Permit Roq'd E3
PROPOSED
inspection Required E3
Sidewalk Required
REQUIRED DEDICATION— IFT
underground
Wiring required
METER SIZE
LINE SIZE
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NO. OF FIXTURES
PRV REQUIRED
YESIJ NO 1:3
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ZIP TELEPHONE j ji�Cvjr i910,02U
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REPAIR
13
GRADING CYDS
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TANK
EiGARAGE
CARPORT
RETAINING WALL
ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN;, -
PLUMBING / MECH
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COMPLIANCE OR
CHANGE OF USE
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SEPA REVIEW
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DESCRIBE WORK TO BE DONE I
HEAT SOURCE
PLAN CHECK NO:
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LOT SLOPE %
VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOI ED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERIMiSS ION.
PERMIT APPLICATION: 180 DAYS
PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 100 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTERESr, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
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
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 LAB9A.QODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATIWNSIJRANCE AND RCW 18.27.
low OR, GENT) DATE SIGNED
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USED IN WATER SERVWE PEPING PROVIDE
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DZPT OF LABOR& E\IDUSI
11DIVI-2:�0 AT425-29,0-1309
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
FEE Description
State Surcharge
City Surcharge
V/-,) Base Fee
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a pennit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
-FICIALS SIG14ATUEIE DATE
ATTENTION E)ff 1333
IT IS UNLAWFUL TO USE OR OCCU PYA BUILDING OR STRUCTURE UNTILA FINAL L
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/IBC110/IRC110.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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FINAL PR03ECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PUASESIGN
—ENGINEERING DIVISION DATE 1'241 OW
1,LrASE SIGN
PLANNING DIVISION DATE
PLEASE SIGN
PROJECT
SITE ADDR-ESS- VWS [0 ��L fte (A)
PERMIT# U0405_+5 ADB# DATE INSPECTED
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:
X 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:forms:ocaprv1 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wail,
Pier/Porch .................
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
Rough -In ....... ........
Convnerclal Pinal .......
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
12-110
..................
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