20040693.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OV/t�ER NAMEINAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
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CITY
NAME
ZIP I TELEPHONE
CBL #
ADDRESS �%J
R390 ue
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CITY
ZIP
TELEPHONE
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(A18
STATE LICENSE NUMBER
EXPIRATION DATE I
CHECRD BY.
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IN.3-
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PROPERTY TAY, AC OUNT PARI NO.
NEW
RESIDENTIAL
PLUMBING / MECH
El ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING FENCE
CYDS ( X FT)
El DEMOLISH
TANK
O-AER
Q_VrR0nF —
GARAGE o
CARPORT
RETAINING WALL FIRE SPRINKLER
ROCKERY FIRE ALARM
(TYPE OF USE, BUSINE�j� ACTIVITY�EXPLAIN:_
w NUMBER NUMff_ER OF CRITICAL
a OF DWELLING AREAS
0 UNITS NUMBER
STORIES
DESCRIBE WORK TO BE DONE
IN
7
1 2V U
HEAT SOURCE GLAZING %
PLAN CHECK NO:
L1
LOT SLOPE %
VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS. DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180 DAYS
LU
IL PERMIT LIMIT., 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
I SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Q ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DII ri-Y OR INDIRECTLY
x FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF *[HIS PERMIT SHALL NOT BE
a TY
j DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY Cl ORDINANCE
12 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 OWNEF REETP OMPLYWITII CITY AND STATE LAWS REGULATING CONSTRUC-
I AGR 'I
TION; AND ll� DOING,, I '. RIK AUTHQ�IZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION;F TrIF�LAqOR �TE THE ITATE OF WASHINGTON RELATING TO
Atr 'r(�
WORKMEN'S C P NS T19N IN E AND CW 18-21 -
I
DATE SIGNED
SIGNATURE (04Eb 6R�b`EN1fl I/
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19
USE
ZONE
JOB
ADDRESS ... ..
PLAT NAMEISUBDIVISION NO
PERMIT EXPIRES
PERMIT J
NUMBER
SUITE/APT#
LOT NO. LID NO.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING - PROPOSED
REQUIRED DEDICATION- F1
METER SIZE LINE SIZE NO. OF FIXTURES
LID FEE $
I ESCP Apmovilid
13
Rvy pormit Required
13
Street use Permit Hoq'd
(3
inspection Required
13
Sidewalk Required
(3
underground
[E�i�
13
PFIV FIE UIRED
YES [3 NO 13
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RACTOR RESPONSIBLE FOR EROSION CONIROL/DRAINAGE go
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE w
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VARIANCE OR CU SHORELINEORADIII I INSPECTION BOND
REO'D POSTED
SEPA REVIEW SIGN AREA OYES ONO S HEIGHT
COMPLETE , EXEMPT ALLOWED , PROPOSED ?ALLOWED , PROPOSED
EXP
LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT)
ALLOWED PROPOSED FRONT SIDE HEAR FRONT UR SIDE REAR
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PARKING LOT AREA I PLANNING REVIEWED BY DATE
REO'D I PROV
REMARKS
CHECKED BY ITYPE
OCCUPANT
GROUP
SPECIAL INSPECTION 'JAREA OCCUPANT
LOAD
REQUIRED [] YES E
REMARKS z
PROGRESS INSPECTIONS PER UBC 1 08/FINAL INSPECTION REQ'D - 3
VALUATION
$ � --�7 /� 7-
L
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapeinsp. 1
Recording Fee
A I-
TAR-1
FOR INSPECTION
(425)
771-02,20
FEE Description
State Surcharge
y
City Surcharge
FEE
Plan Chk. Deposit
Receipt #
TotalAmt.Due
Receipt # -21LIZ
APPLICATION APPROVAL
This application is not a permit until signed by the
Building 011icial or his/her Deputy: and roes are paid, and
receipt is acknowledged in space provided.
4FICIAC5 SIGNATURE�i PATE
RVJ.EASED BY
ATTEN'TiO� - U2 j f EXT 1333 LL�
IT IS UNLAWFUL\TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES
ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
GREEN - ACCOUNTING
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch .................
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Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
0 M
C
Rough -In ...................
M
--1 0
0 0
Commercial Final ......
C:
HEATING:
M
M Z
Gas Test ....................
C _Z
F-
Gas Piping .................
3:
Cn
Equipment .................
0 -n
n
-1
Commercial Final .......
3:9
M M
EXTERIOR SHEATHING
0 Cn
NAILING..........................
0
0 ITI
FRAMING ........................
C 0) t
90)
Q 0
FIRST FLOOR FRAMING ...
Z r—
INSULATION ...................
X
--I
Floor Insulation .........
:C
>
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Wall Insulation ...........
Ceiling Insulation .......
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SHEETROCK NAILING ...
0.
I
SPECIAL INSPECTION
0
171
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MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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