20040769.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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NAME
ADDRESS
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PLAT NAME/SUBDIVISION NO.
PERMIT EXPIRES
PERMIT
NUMBEI`3�t�/v
LOT NO.
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING — PROPOSED
REQUIRED DEDICATION— FT
METER SIZE I LINE SIZE I NO. OF FIXTURES
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LID NO,
LID FEE S
IESCP Approved
C3
C3
RW permit Required
13
Street Use permit Rori'd
inspection Required
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S,dewjjj� Required
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Underground
E3
Wiring required
PRV REQUIRED
YES E3 NO 13
REMARKS
OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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STATE LICENSE NUMBER
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PROPERTY TAX ACCOUNT PARCEL NO.
NEW RESIDENTIAL
PLUMBING / MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING CYDS
0
FENCE X
FT
DEMOLISH
TANK
OTHER
GARAGE
RETAIN ING WALL
FIRE SPRINKLER
FIRE ALARM
CARPORT
ROCKERY
(TYPE OF USE, BUSINESS,04j
ACTIVITY) EXPLAIN:
NUMBER
OF
NUMBER OF
DWEL , LING
CRITICAL
AREAS
STORIES
UNITS
NUMBER
DESCRIBEI WORK TO BE DONE
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
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: 180DAYS
PERMIT LIMIT. 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
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
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEFS, 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 MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS ABILITY 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 AUTIIORIZED THEREBY. NO PERSON WILL. BE EMPLOYED
IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
SIGNATURE (OWNER OFAGENT)
(& I DATE SIG7/
FIRE REVIEWED BY
DATE
BOND
VARIANCE OR CU SHORELINE OR ADBN NSREO ON POSTED
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YES INU S HEIGHT
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SEPA REVIEW
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SIGN AREA
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ALLOWED I PROPOSED
EXP
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LOT COVERAGE
REQUIRED SETBACKS (FT)
PROPOSED SETBACKS (FT)
ALLOWED PROPOSED
FRONT SIDE REAR
REAR
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REMARKS
CHECKED BY ITYLE—OF
OCCUPANT
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SPECIAL INSPECTION I AREA uuuur^
REQUIRED[] L��AD
.................
REMARKS z
PROGRESS INSPECTIONS PER UBC 108/IBC1091IRC109 FINAL INSPECTION REO'D
M
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire inspection
LandscapeInsp.
Recording Fee
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
CALL
FOR INSPECTION
(425)
771-0220
cv�r -102firl
Plan Chk. Deposit
Receipt
Total Amt. Due 1�5
Receipt #
APPLICATION APPROVAL
This application is not a perrT it until signed by the
Building Otlicial or his/her Deputy and Fees are paid, and
receipt is acknowledged in space provided.
IC SIG JA RE DATE
OATE
ATTENTION I
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVALOR A 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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DATE:
N4EMO TO: PE OORDIN BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE_L�) -7
PLEASE WN
ENGINEERING DIVISION DATE
Pj.F,%_,;l! SIGN
PLANNING DIVISION DATE
PLEASr SIGN
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PROJECT J
SITE ADDRESS-
04 7 ADB# DATE INSPECTED
PERMIT #
DESCRIPTION OF WORK TO BE INSPECTED—U C--
A field inspection Nvas conducted to determine compliance. with -approved plans. Final approval
e above signed Department to the release of
denotes that there are no objections from th
PERFORMANCE BONDS and the granting of:
04,1-)GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
El Copy of CONDITIONS given to owner/contractor by inspector
I .
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
El Copy of CORRECTION NOTICE given to owner/contractor by hipector
2.
9A
RE -INSPECTED OUTSTAN-DING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
I:teilip:blcig:fornis:ocal)i-\,I 3125/04
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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:
Gas Test ....................
Gas Piping .................
Equipment .................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST FLOOR FRAMING...
INSULATION ...................
Floor Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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