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PERMIT EXPIRES�
DATE RECEIVED
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CITY OF EDMONDS
I- PERMIT
NUMBER 77((
CONSTRUCTION PERMIT APPLICATION JOB
: ADDRESS
SUITE/APT#
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OWNER NAME/NAME OF BUSINESS
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NAME/SUBDIVISION NO. LOT NO.
LID NO
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
LID FEE
'ESCP App'o"d (3
Rvy prMd 9,q .. led 13
Street Use permit Roli'd (3
inspection Rocitived 13
Sidewalk Required (3
Underground 0
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MAILING ADDRESS
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CITY ZIP
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TELEPHONE
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METER SIZE
LINE SIZE
OF FIXTURES
PRV REQUIRED
YES NO 13
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NAME
ADDRESS REMARKS
OWN
E R/CON TRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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CITY ZIP
TELEPHONE
NAME
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REVIEWED BY DATE
ADDRESS
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REVIEWED BY DATE
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CITY ZIP
TEL PHONE
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VARIANCE OR CLI
SHORELINE OR ADB#
INSPECTION
REQ
OYES ONO
BOND
POSTED
1 $
STATE LICENSE NUMBER EXPIRATION DATE
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TA 6/4� Lt� L 0%
SEPA REVIEW
COMPLETE , EXEMPT
SIGN AREA
ALLOWED PROPOSED
HEIGHT
ALLOWED PROPOSED
PROPERTY TAX ACCOUNT PARCEL NO.
(X)
EXP
n NEW )jZ"R'ESIDENTIAL PLUMBING / MECH ALLOWED
COMPLIANCE OR
M ADDITION E] COMMERCIAL CHANGE OF USE
REMODEL El MULTIFAMILY SIGN
LOT COVERAGE
PROPOsW
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—PROPOSED SETBACKS (FT)
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PARKING At
PROVIDED
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GRADING o FENCE
REPAIR CYDS x Fr)
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DEMOLISH TANK El 0
REMARKS
EiGARAGE FIETAININGWALL FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
UYPE OF USE. BUSINESS OR ACTIVITY) EXPLAIN:
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CHECKED BY
TY=ION
OCCUPANt? T_�
GROUP
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NUMBER
OF
STORIES
NUMBER OF
DWELLING
UNITS
CRITICAL
CR'T"
7A R E AS
NUMBER
N UMB N14
]PROGRESS
SPECIAL INSPECTION'
REQUIRED [] YES
JAREA
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK NO: I VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
1= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
M PERMIT APPLICATION: 180DAYS
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 SUCCESORS
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IN INTEREST, AGREES TO 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 INDIREC 11-Y
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
P 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 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 LA R '6 - OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATY�W<SURNACE AND RCW 18,27.
9TC9A-TURE (OWNER OR �ED
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VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
LandscapeInsp.
Recording Fee
CALL
FOR INSPECTION
(425)
771-0220
ATT ENTION E)ff 1333
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
FEE Description FEE
State Surcharge
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City Surcharge
Base Fee
Plan Chk. Deposit
Receipt
Total Amt. Due
Receipt
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space Provided.
EEIMALS ilGN1hURE 1�11
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09iO3 PRESS HARD -YOU ARE MAKING 4 COPIES
DATE
ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
A 4 TO:
t)EVELOPMrt4y
r,jr, OF DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
�Ijp EASESIGN
ENGINEERING DIVISION DJE
PLEASE SIGN
PLANNING DIVISION DATE
PLEASESIGN
PROJECT r
SITF ADDRESS q,�A A /J
0'4tv� 4 - (9 % 4 AD B # DATE INSPECTED
PERMIT #
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:
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
E] Copy of CONDITIONS given to owner/contractor by inspector
1 .
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1:temp:b1dg:fon-ns:ocaprv1 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
Pier/Porch ................. z
0
Retaining Wall ...........
0
Slab Insulation ..........
PLUMBING:
Underground .............
0 M
C
Rough -In ................... M
0
-40
C�rnr�efcial Fin'a4l 0 C
HEATING: M
M z
Gas Test .................... C
z
Gas Piping ................. x
Equipment ................. 0
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Commercial Final ....... -4
3:9
M M
EXTERIOR SHEATHING 0
0
NAILING ..........................
0 M
C: (D
FRAMING ........................ 9 C/)
M 0
FIRST FLOOR FRAMING ... Z r-
INSULATION ...................
Floor Insulation .........
z
Wall Insulation ...........
3:
Ceiling Insulation .......
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SHEETROCK NAILING ... 0
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0
SPECIAL INSPECTION ... 171
MISCELLANEOUS ..........
FINAL APPROVAL-FE)R t13
4)&,�Cy ..................
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