20040553.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS; P
MAILING ADDRESS
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CITY ZIP TELEPHONE
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CITY ' / XP / [TELEPHONE
PERMIT EXPIRES
USE PERMIT
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NUMBER
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JOB SUITE/APT#
ADDRESS -.09e)
LX 112�1
PLAT NAME/SUBDIVISION NO LOT NO. LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCP Approved
FJW Permit Required
Street Use Permit Roq'd
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EXISTING — PROPOSED
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Inspection Required
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Sidewalk Requited
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REQUIRED DEDICATION- FT
Underground
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Wiring required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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YES 0 NO
REMARKS
OWN ER/CON TRACTOR RESPONSIBLE FOR EROSION CONTROLJDRAINAGE
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ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE
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SHORELINE OR ADB#
INSPECTION
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OYES ONO
BOND
POSTED
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STAI�,LICENSE NUMBER EXPI ATION DATE
ECKDED BY
SEPA REVIEW
COMPLETE , EXEMPT
EXP
SIGN AREA
ALLOWED PROPOSED
HEIGHT
PROP
ALLOWED OSED
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PROPERTY TAX AgCOUNT PARCEL No f
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NEW P�RESIDENTIAL PLUMBING MECH
COMPLIANCE OR
ADDITION COMMERCIAL
CHANGE OF USE
REMODEL MULTIFAMILY SIGN
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT UR SIDE REAR
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PARKING i I
REO'D I PROVIDED
LOT AREA
PLANNING REVIEWED BY DATE
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GRADING FENCE
REPAIR 1:3 CYDS El (_x FT)
REMARKS rlR� MAK6FiA!-
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GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT 1:1 ROCKERY El FIRE ALARM
MU,�_T bIzz HHESENT
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IiANK FILL, Rtivlft #t eR GAP
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NUMBER
OF
STORIES 1...
NUMBER OF
DWELLING
UNITS
CRITICAL
AREAS,
NUMBE
SPECIAl. _GN
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REQUIRED S
YES
AREA
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
GRESS INSPECTIONS PER UBC 108/IBC109/IRC109 FINAL INSPECTION REQ'D
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VALUATION
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Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
GIAZING %
LOT SLOPE %
Building Permit
City Surcharge
PLAN CHECK NO:
VESTED DATE
Plumbing
Base Fee
Mechanical
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. 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 PERMISSION.
Grading
Engr. Review
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PERMIT APPLICATION: 180DAYS
PERMIT LIMIT 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
Engr. Inspection
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'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
IN INTEREST, 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.'
Fire Review
Plan Chk. Deposit
Fire Inspection
Receir I #
Landscapelnsp.
Total Amt. Due
Recording Fee
Receipt #
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-
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 CQURZNSATION INSURANC5,AtM)RCW 18.27.
CALL
FOR INSPECTION
(425)
771-0220
1 his application is not a perinif until signed by the
Building Official or hisilier Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
771TIALS SIGNATURE DA E
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SIGNATU OW ER OR G NTt
DATE WNED
I
fiY DA E
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ATTENTION EXT 1333
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFICATE OF OCCU-
ORIGINAL - FILE YELLOW - INSPECTOR
PANCY HAS BEEN GRANTED. UBC109iIBC110/IRC110. PINK - OWNER GOLD - ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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FINAL PROACT APPROVAL FORM
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TO:
D ATE: Lo 14
JUL 2 3 2004
DEVELOPMENT SERVICES CTR.
CITY OF EDMONDS
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: c7 -FIRE DEPARTMENT DATE
PlLr�N
ENGINEERING DIVISION DATE
PLEASE SIGN
PLANNING DIVISION DATE
PLEASE SIGN
PROJECT
SITE ADDRESS- C;-
PERMIT ADB# DATE INSPECTED Z/--,),D- - k) "d
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:
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GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
El Copy of CONDITIONS given to owner/contractor by inspector
1 1.
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
1 .
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:fonns:ocaprv1 �/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 ....................
GasPiping .................
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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