20040593 (2).pdfDATE RECEIVED 4 1
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINES
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
PERMIT EXPIRES
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PERMIT
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NUMBER'�
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SUITE/APT#
PLAT NAME/SUBDIVISION 140.
LOT NO,
LID NO.
LID FEE $
PU13LIC RIGIIT OF WAY PER OFFICIAL STREET MAP
7ESCP Approved 13
RW Permit Required Q
Street Use Permit Roq'd 13
EXISTING - PROPOSED
Inspection Required E3
Sidewalk Required E3
REQUIRED DEDICATION-
Fr
Underground
I Wiling required E3
METER SIZE
LINE SIZE
NO. OF FIXTURES
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I PRV REQUIRED
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STATE LICENSE NUMBER EXPIR"IFION
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NEW
RESIDENTIAL
PLUMBING I MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
El CHANGE OF USE
El REMODEL
$.MULTIFAMILY
SIGN
REPAIR
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CYDS
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DEMOLISH
TANK
GARAGE
CARPORT
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ROCKERY
El FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSItAS-5..PFLAPLIVn-Y).�XPLAIN:
NUMBER NUMBER OF
OF DWELLING
STORIES I UNITS
DESCRIBE WORK TO BE DONE
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HEAT SOURCE
PLAN CHECK NO:
GLAZING %
CRITICAL
AREAS
NUMBER
LOT SLOPE %
VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS. SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180DAYS
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CL PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
U) 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCFSORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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< ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIREC Y
x FROM THE ISSUANCE OF I HIS PERMIT ISSUANCE OF 1 HIS PERMI1 SHAI I NOT BE
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DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAYTHE 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 wini CITY AND STATE LAWS REGULATING CONSTRUC-
TION AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYEE)
IN ViOLATION OF THE LA13OR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
SIGNATURE (OWNER o(/(��
k 147
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I DATE SIGNED
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
VARIANCE OR CLI RELINEORADB# I INSPECTION BOND
IC3YREO'D POSTED
ES ;X�O S
SEPA REVIEW SIG AREA HEIGHT
COMPLETE , EXEMPT ALLOWED PROPOSED ALLOWED SED
EXP I I PROPO
LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (FT)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/R SIDE REAR
PARKING LOT AREA _[ PLANNING F EVIEWED BY DATE
REO'D I PROVIDED 7;
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CHECKED BY JTYPJJ C
GROUP
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SPECIAL INSPECTION- AREA OCCUPANT
REQUIRED [] � I U LOAD
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PROGRESS INSPECTIONS PER UBC 108/ IBC109/ IRC109 FINAL INSPECTION REQ'D 1 5
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Description FEE Description FEE
Plan Check State Surcharge
City Surcharge
Building Permit q- L.)
Plumbing Base Fee
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review Plan Chk. Deposit
Fire Inspection Receipt #
Landscapelnsp. Total Amt. Due
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Recording Fee E ipt iff -212
APPLICATION APPROVAL
I his application is not a permit until signed by the
CALL Building official or his/tier Deputy and Fees are paid, acid
FOR INSPECTION receipt is acknowledged in space provided.
OF I AL3 SIGNASUR, UJI E
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771-0220 "CLEASED BY DATE
A17ENTION MA I I ja*3
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILA FINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/IBC110/IRCIIO.
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:
GasTest ....................
Gas Piping .................
Equipment .................
Commercial Final .......
EXTERIOR SHEATHING
NAILING..........................
FRAMING........................
FIRST FLOOR FRAMING ...
INSULATION ...................
Floor insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
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MISCELLANEOUS ..........
2
FINAL APPROVAL FOR
OCCUPANCY ..................
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