20040782.pdfI
DATE RECEIVED
q,11 ERMIT EXPIRES
/W/21/1 FP 7- 7
USE PERMIT
CITY OF EDMONDS
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ADDRESS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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PLAT NAME/SUBDIVISION NO. LOT NO.
LID NO.
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LID FEE $
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MAILING ADDRESS
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
TIESCIR Approved
RW Permit Required
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EXISTING — PROPOSED
REQUIRED DEDICATION— FT
Street Use Permit Roq'd
Inspection Required
Sidewalk Required
Underground
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CITY ZIP
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TELEPHONE
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Wiring required
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METER SIZE
LINE SIZE
NO. OF FIXTUR
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RV REQUIRED
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ADDRESS
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY DATE
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FIRE REVIEWED BY DATE
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CITY ZIP
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VARIANCE OR CU
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INSPECTION
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STATE LICENSE NUMBER `IkXPIRAYION bA E
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ALLOWED I PROPOSED
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RESIDENTIAL (!LgUM�ING�/ MECH
COMPLIANCE OR
COMMERCIAL CHANGE OF USE
MULTIFAMILY SIGN
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT.)
FRONT SIDE REAR
PROPOSED SETBACKS (Fr.)
FRONT LJR SIDE REAR
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PARKING
REO'D I PROVIDED
LOT AREA
PLANNING REVIEWED BY DATE
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GRADING FENCE
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REMARKS
DEMOLISH
OTHER
TANK
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RETAINING WALL FIRE SPRINKLER
ROCKERY FIRE ALARM
(TYPE OF USE. BUSINESS OR ACTIVITY) EXPLAIN:.
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CHECKED BY
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CODE
OCCUPANT
GROUP
WUM13ER
OF
STORIES
NUMBER OF
DWELLING
UNITS A//A_
bRITICAL
AREAS
NUMBER
SPECIAL INSPECTION JAREA
REQUIRED
OCCUPA_I+T
LOAD
DESCRIBE WORK TO BE DONE
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REMARKS
PROGRESS INSPEC71ONS PER UBC 108/IBC109/IRC109 FINALINSPECnON REQ'D-
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VALUATION
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Description FEE Description FEE
Plan Check State Surcharge
HEAT SOURCE GLAZING % LOT SLOPE % Building Permit City Surcharge
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PLAN CHECK NO: VESTED DATE Plumbing Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC Grading
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Engr. Review
Lu PERMIT APPLICATION: 180 DAYS
IL PERMIT LIMIT 1 YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS Engr. Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS Fire Review Plan Chk. Deposit
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IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND Fire Inspection Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
x FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
a DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE Landscapelnsp. Total Amt. Due
0 NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
Recording Fee Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION APPLICATION APPROVAL
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- This application is not a permit until signed by the
TION; AND IN DOVG�THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED CALL Building Official or his/tier Deputy: and Fees are paid. and
IN VIOLATIO�*i!FF T/9E LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKM5>eCO5PENSATION INSURANCE AND RCW 18.27. 11� I OFFICIAL I U E DATE
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771-0220 REL WD BY., 'ATE
ATIkERTION EXT 1333
PMBIT IS UNLAWFULTO USE OR 025U�FWA ltlllll'� R'STRUCTURE NTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU- ORIGINAL - FILE YELLOW INSPATOR/
PANCY HAS BEEN GRANTED. UBC1 09 / IBC1 10 / IRC1 10. PINK - OWNER - GOLD - ASSESSOR
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch .................
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
On
Rough -In ...................
Commercial Final ......
HEATING:
GasTest ....................
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
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nr1r11PANry ----- ............
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