20040673.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINESS
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NAME
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ADDRESS
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NAME
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ADDRESS 1
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION
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X/1-co(f -*iir4r44G
PROPERTY TAX ACCOUNTPARCEL NO.
NEW RESIDENTIAL
ADDITION COMMERCIAL
REMODEL MULTIFAMILY
REPAIR GRADING CYDS
DEMOLISH TANK
GARAGE RETAINING WALL
CARPORT ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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Lu NUMBER
NUMBER OF
OF
DWELLING
I
o STORIES
UNITS
DESCRIBE WORK TO BE DONE If
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BY
PLUMBING / MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
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OTHER
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FIRE SPRINKLER
FIRE ALARM
CRITICAL
AREAS
NUMBER
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PERMIT EXPIRES
USE
ZONE
PERMIT
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N U M B E R 2m
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JOB
SUITE/APT#
ADDRESS
PLAT NAME/SUBDIVISION NO,
LOTAO.
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
I ESCP Approved
Rw Permit nortuired
13
13
Street Use Permit Roq'd
E3
EXISTING —
PROPOSED
inspection Rtiquired
Sidewalk Reqtjlrod
REQUIRE[) DEDICATION— FT
Undeigrotind
E3
Wiring required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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YES 0 NO 13
REMARKS
OWNER/CON TRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE W
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VARIANCE OR CU SHORELINE OR ADB# INSPECTION I 13OND
REO'D POSTED
IE�k ZY.- OYES B NO S
SEPA REVIEW SIGN AREA HEIGHT
COMPLETE , EXEMPT ALLOWED I PROPOSED ALLOWED , PROPOSED
EXP V A/ (� AIL
LOT COVERAGE REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (FT)
ALI-OWED PROPOSED FRONT SIDE REAR FRONT UR SIDE REAR
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PARKING LOT AREA PLANNING REVIEWED BY DATE
REO'D PROVIDED
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REMARKS ( fj
CHECKEDBY JT.YPE OF CONSTRUCTION GO E CUPANT
GROUP
21-7 oc
SPECIAL INSPECTIO� JA
,W- r L, qborJ"�F OCCUPANT
REQUIREDEj YES LOAD
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PROGRESS INSPECTIONS PER UBC I 08/FINAL INSPECTION REQ'D I Ei
VALUATION
$ 4 Bl ?,
Description
FEE
Description
FEE
Plan Check
State Surcharge
HEAT SOURCE
GLAZING %
LOT SLOPE %
Building Permit
City Surcharge
PLAN CHECK NO:
VESTED DATE
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
W PERMIT APPLICATION: ISO DAYS
9L PERMIT LIMIT: 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
(Al Fire Review Plan Chk. Deposit
W 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
uj IN INTEREST. AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES. AND AGENTS FROM ANY AND Fire Inspection Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIREC I LY OR INDIREC1 LY
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT HE
DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapelnsp. Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION. -
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION. THAT THE INFORMATION Recording Fee Receipt III
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF APPLICATION APPROVAL
THE OWNER. I AGREE TO COMPLY WITI I CITY AND STATE LAWS REGULATING CONSTRUC- CALL I his application is not a permit until signed by the
TION AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/her Deputy: and Fees are paid, and
IN VI'6LATION OF THE LABOR,CODE--QF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN't COMPEN�qibN MORANCti,'AND RCW 18 27. OFFICIA iN�r
,j,X-�)SIGN T
D.ATE
SIG]N DATE ZSIEXD t
(QWNEROA�N (425)
.00
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771-0220 RELEASED BY ATE
i 1 4-
ATTENTION ctaf�A, EXT 1333
SE 0 A B1 -ING OR STRUCTUR
IT IS UNLA� R OCCOI�y Al it UNTIL
A FINAL INSPECTION HAS-BEEN MADE AND APPROVAL OR A CERTIFI- ORIGINd-Fj) YELLOW-14SPE OR
CATE OF OCCUPA14CY HAS BEEN GRANTED. UBC SECTION 109 PINK-6WOER GOLD -ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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CInit" OF EDMONDS
SPE CIAL INSPECTION AND TESTING AGRE EMENT
Theprojectat/kO LU issued under buildin
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permit number Y. equires spccia inspSction and/or test' er UBC Chapter 1�
'ng
and WAC Amendments 1702, 'Ille complete list of special inspections is a"acbcTto Us document.
BEFORE A PERNUT CAN BE ISSUED: The owner and contractor and special inspector shall
complete this a&reement and the attached structural test(s) and insp=tions schedule including the
required aciciowledgments.
APPROVAL OF SPECIAL INSPECTORS: Each special inspector shall be approved by the
Building Official prior to perfbnnin�an duties 9r.inspections. Each special inspector shall nibmit'
Statement of qualifications to the uilydi g Official for review. Special inspectors shall display'
identification when perfornii'rig special inspections on site. Special inspection and testing shall meet
the minimum requirements of UBC Chapter 17 and the folloNvifig:
A. -Duties and Respousibilities of tht3vtdaLlaivi=
1. Observe Work
The special inspector shall observe the site work for conformance with the approved
(stamped) plans. and sp�cifications and applicable workmanship provisions of the UBC.
Architect or En�ineer reviewed shop drawings may be used only as an aid to inspection.
§pecial inspectaons are to be performed on a continuous basis --meaning that the special
inspectonis on site at all times observing the work requiring special inspection.. Periodic
inspections, if any, must have prior approval by the City.based on a separate written plan
reviewed and approved by the Building Official and the engineer or architect of record.
2. Report Non-conforn2ing Items
The special inspector shall bring nonconforming items to the �nmediat; attention of the
contractor and note. all such items in the daily field report, Any item not resolved in a timely
manner shall be immediate cause of the special inspector to notify the Building Official of the
plan dev�iadon error, change or ornission. It shall also be the duty of the special inspector to
promptly noti�y the. engineer or arcWtect-
3. Complete Daily Reports
Each special inspector shall complete and sign both the spe-cial inspection record and the daily
report form for each day's inspecfion. These records shall remain at the jobsite with the
contractor for review by the City Building Inspector.
4. Furnisb Weekly Reports
The special inspector or in,spection agency shall fumish the City vAth weekly reports of tests
and ffispecdons. The project engineer or architect, and others as designated shall also be
copied on reports. Weekly reports must include the following:
Descn tion of daily inspections and tests made with applicable locations
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List or all nonconforming items
Report on status of nonconforming items (resolved or unresolved)
Itemized changes authorized by the Architect, Engineer and City if not included in
nonconformance items
5.* Furnish Final Construction Report
The 7 i.al ector or inspection agency shall submit a final signed re
lec -port to the City stating
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that a equiling special inspection and testing were fulfilled and reported. And, to the
best of his/her knowledge the project is in conformance with the approved plans and
specifications, app�oved change orders and the applicable worlananship provisions of the
TJBC. Items not in conformance or unresolved items or any discrepancies in inspecdon
coverage, (i.e., missed inspections, periodic inspection when continuous inspections were
required, etc.) shall be speci6cally iteiiiized in this report.
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Jul 13 04 09:59a CASCADE TESTING 425-823-2203 P.1
- --I . :1; 4 tiArA i rAUM 014
34; 49 P. 04,,05
I Notify the SPedal Imolmetor
It is the duty otthe contractor to notify the special inspector when work is ready for special
insPection. Note, dw item listed On the attached schedule ad U noted on the approved
plans xad specifications am required to hAVO special inapeefiong. Adequate notice stall be
pro%ided by tha c6aftutor so that the qw1al inspector has time to become farr�liu with the
yrDjccl.
2. Provide Amss to Approved Plans
The contractor is respoitsible for providing th5 sPedAl inlPcctor seem to approved plans at
the jobizitc.
3. RtUlD Special Inspecdon Records
The coutrutor is responsible to reWn al th 'ob
IF, t 11te 911 NP00181 iWeption mcords nbmitted
by the special inepactor. 7bece recor& arc to a provided to the City -building inspector upon
request.
1. A
Alprove special Inspettors or iuWwticw agencies
e building department Shall kpprove all special inspectors and special inspecTion
roquiruments.
2. Monitor special (zopecHon aDd m1piprove weekl� rtports
Work inspection and the ormance of spechki inspeclors.sball, be
rnoiftitZ 7beVC�ity Bullcliq lnq=tQr. risfl�
oon 'ACT approval must be obtainw! prior to
plament o concrete or other oftlar activities in addition to that of the special inq=tor,
3. Issue Certificate of Occupancy
ne SWIding Official may issue a Certificate of Occupancy after all weeldy'special inspection
reposu including tk final report have been nibrnittcd and accepte&
D. Owner ResUgn2lbilitin
The PTj=1 owner or the erigmeer or Architect of reoDrd acting as the owner'll agent "I Awd
SPVC1111 1118pecti011 SeMCCL
Wd Res'ponsffilada
71a ensinea or arcWtoct of record shall inchAc spociaJ inspection requimments an the plans and
spocifications.
ACKNOWLEDGEMENTS
I have read and agree to comply uith the ternu and oonditionv ethis agrmmew.
owna
at 17-11—
Te
Special M/Spector V. E--JDate
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General Contr 4_�
act��d
City BaBding
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— Stoop M alitrial Iditntirewicia
_ZwCl&ng Inspmdori 0 S") 215w�id
UJITILSOnic IFISPKILiDn 0 Shop C3 Field
Histi-stretio Bulting
litspicuicin (D Shop 0 Field
0 A325 D N 0 X 0
E) A490
Metal Utek Welding Intpection
Rcinforcing Steel Wilding IuTp�cdon
Mcul Stud Welding Irupoction
'PRECASTIPRESTRESSED CONCRETE: Con=tc Inxert Wcldkg Inspmion
PUs Poirt-Tew Prit,.Tgra CWdlng
A ��Fwc Tests
PAinfaircring Ters
Tuvion Tesu
Mix Desirms
Reinfoitin; Placement
Inse-n Piscemcrit
Cob=te Batchink
com-m-fe Platca=1
Immiladon Insepcdon
C25t Sammes
Pick-up Sunplirs;
Co=rwion Tests
-71
Fl. 05/05
arr.;—LAJ, LNbf'hf— I JUN A.N011SITING SCHEDULE
"OrECT ADO"M Mrwro;%
REINFORCED CONCRETEt GUNMI GROUT AND MORTAR: STRUCTURAL STE, ELIWELDIING:
Cwwtnu Girinilt Grant mortir —Sample Lrid7estniv xp f'tcrrw=bcnbdcrw)
TAAFM;!sl; Tests
I Reinforcing Tests
j
Mix Dc34ns
Reirdominy Placc".nj
Ditch Plant Insvcc6an
Inspect PLacing
CAM Samples
Pick-up i�&mples
CornEritssiori Tesu
FIRE, PROOFING:
Ptwx=nt Inspemion
DeruilyTeas
1'6ckmu Tests
Irupect Batching
INSULATING CONCRETE:
- Sample and Test
— Placement Inspection
— Unit Weights
MLL MATERIAL;
. Acccpunce Tests
MASONRY — Flaccrilcm Inspection
— Special InsFcclion Stresm Used — Field Dcushy
— Preliminary A=pLzxc Tests (MLwrLry Uniu. Wall Prisms)
— Subsequent Tests fMonar. Ormt, Field Wall Mims) STRUCTURAL WOOD!
Placement Insptcdon of Unju She= Wall Nailing Inspection
i�`=I purion of Clu-1am Fab.
Spwwion ol"l-russ )oist Fab.
ADDITIONAL INSTRUCTIONS OR OTHER TESTS Swriple and'rest Compoixnu
AND INSPECTIONS;
.� 1. � A . - — -4 .9 " _.� - . . /j —A
Form completed by: 71tie:
Talephoar No,: Dwe:
TOTRI� 0. 05
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: UILDING DIVISION
:0
FROM: FIRE DEPARTMENT DATE
PLWF SKM ENGINEERING DIVISION DATE
PLZASE SIGN
PLANNING DIVISION DATE
KXASE Sim
PROJEC
SITEADDRESS
PERMIT ADB#_DATE INSPECTED
DESCRIPTION OF WORK TO BE INSPECTED 7—
A field inspection was conducted to determine final 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 FENAL, PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
c3 Copy of CONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
ci Copy of CORRECTION NOTICE given to owner/contractorby inspector
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Si
ocaprvl.doc.l:temp:bldg:formsIO/OI
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
40( 2 y �/, X
Footing ......................
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...................
Pier/Porch .................
Retaining Wall ...........
Slab insulation ..........
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PLUMBING:
0
Undergroun d .............
Rough -In ...................
63
Commercial Final ......
HEATING:
03
Gas Test ....................
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Gas Piping .................
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Equipment .................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST FLOOR FRAMING ...
0-7
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
qyy,
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
00 kwo&73 60000'
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