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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
17 o 7 /9-
CITY ZIP TELEPHONE
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NAME
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ZIP [TELEPHONE
NAME
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ADDRESS
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CITY ZIP
4) 71 / <Re�p
LEPHONE
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STATE LICENSE NUMBER
EXPIRATION
DATE
CHECKED BY
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PROPERTY TAX ACCOUNT PARCEL NO.'
Ll 6 17 4) 4)
1
NEW
RESIDENTIAL
a'PLUMBING / MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
1:1 CHANGE OF USE
53�RREMODEL
1:1 MULTIFAMILY
SIGN
REPAIR
GRADING rynq
c FENCE
( X FT)
DEMOLISH
TANK
OTHER
GARAGE
CARPORT
o RETAINING WALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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NUMBER NUMBER OF CA ITICAL
OF DWELLING AREAS
0 STORIES UNITS MBER
DESCRIBE WORK TO BE DONE r)
,0
wzo
HEAT SOURCE GLAZING % LOT SLOPE %
PLAN CHECK NO: VESTED DATE
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.
M
Lu PERMIT APPLICATION: 180 DAYS
QL PERMIT LIMIT. 1 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 SUCCESORS
I IN INTEREST, AGREES 10 INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
2 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 MODIF'� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITTS ABIL11Y 10 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 LAQQB_QODE OF TjiE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPEWATrO-N INS`LWNCEAND RCW 16.27.
LOR �E DATE SIGNED 4
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ADDRESS
PLAT NAME/SUBDIVISION NO.
PERMIT EXPIRES
PERMIT
NUMBER (17) q.
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LOT NO. LID NO.
LID FEE S
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PUBLIC RIGHT 0
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YES 0 NO 0
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REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLYDRAINAGE
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ENGINEERING REVIEw"Pf r.Y A CC EPTED
FIRE REVIEWED BY
EXP I
LOT COVERAGE
ALLOWED PR OPOSED
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DATE
DATE
BOND
POSTED
HEIGHT
wi�-1 PROPOSED
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REQUIRED SETBACKS (FT.) I PROPOSED SETBACKRSEA(FT)
FRONT SIDE REAR FRONT UR SID E R
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relief ;a�lveq an approved
CHECKED BY ITYPE C T CTION CUPANT
1 D OCI
C6 "_� I GRi
SPECIAL INSPECTION JAREA LOAD
REQUIRED [] YES OCCUPANT
REMARKS z
PROGRESS INSPECTIONS PER UBC 108/IBC109/lRC109 FINAL INSPECTION REQ'D
PMUANT TO UPC 608
APRESSMEICE(A] A_DDRVALVE(PRN�
0" A Ir v
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscape Insp.
Recording Fee
CALL
FOR INSPECTI(
(425) (
771-0220r
WATERS-11FUTOFF
FEE Description
State Surcharge
City Surcharge
72 Base Fee
FEE
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IV.P(li
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt 0 17 1 -7
APPLICATION APPROVAL
This application is not a permit until signed by III
Building Official or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided+ I
FACIAYS JIGNATURF/ / .-%.DITE,�
Rrfr-A;ED
ATTENTION DIU 1333 161
ITIS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
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
ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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RECORD'OF INSPECTIONS
INSPECTOR DATE APPROVED
SET13ACKS ..........
FOUNDATIQK:
Fo6ii,,,g
Wall..........................
Pier/Porch .................
Retaining Wall ........... z
0
Slab Insulation .............
0
M
PLUMBING:
Underground ............. :q 9
Rough -In ...................
M
C
Commercial Final ... M
0
-40
HEATING: 0
c-N M
Gas Test .................... M z
GasPiping . .................... z
r
Equipment .................
Commercial Final ....... 0 _n
EXTERIOR SHEATHING af
NAILING .......................... M M
FRAMING ........................ 0 r
0 M
FIRST FLOOR FRAMING... C: cl)
9 C/)
Q 0
INSU:'ifA�IdN ........... Z
Floor Insulation ......... X
--I
Wall Insulation ........... >
z
Ceiling Insulation ....... __11
SHEETROCK NAILING W
z
SPECIAL INSPECTION ... 0
0
ITI
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ............. 1vnL
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