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DATE RECEIVED C,
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEMAME OF BUSINESS
MAILING ADDRESS
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NAME
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-STAtE LICENSE NUMBER EXPIRATION DATE CHE BY
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PROPERTY TAX ACCOUNT PARCEL NO
NEW
RESIDENTIAL
ADDITION
COMMERCIAL
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
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GARAGE
CARPORT
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RETAINING WALL
ROCKERY
(TYPE OF USE, BUSINESS OIj4P:rjVnyrfX.PL4PN:
rd NUMBER NOMBEROF
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DESCRIBE WORK TO BE DONE
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HEAT SOURCE I GLAZING %
PLUMBING / MECH
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COMPLIANCE OR
CHANGE OF USE
SIGN
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( X FT)
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FIRE ALARM
CRITICAL
AREAS
NUMBER
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.
PERMIT APPLICATION: 160DAYS
PERMIT LIMIT. I 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, EMPLOYEES. AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NAI URE, ARISING DIRECTLY OR INDIRECI LY
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT HE
DEEMED TO MODIF'� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION.4
I HEREBY ACKNOWLEDGE THATI 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 LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENS4TIOT44MURANCE AND RCW 10,27.
17 KA
,/TURE.,OWNE7r,Aj QE,N I DATE SIGNED
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I PERMIT EXPIRES
USE PERMIT
ZONE NUM9ER
JOB
ADDRESS
'SUITE,/�T#,
PLAT NAME/SUBDIVISION NO,
LqT NO.
LID NO.
LID FEE $
PU13LIC RIGHT OF WAY PER OFFICIAL STREET MAP
TESCIR Approvod
RW Permit Required
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Street use Pairnit Raq'd
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EXISTING — PROPOSED
inspection Roitti-rad
13
Sidewalk Roquirrid
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REQUIRED DEDICATION— FT
Underground
Wiring ioquited
13
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
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REMARKS
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OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY DATE
FIRE REVIIEW�D BY DATE tu
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VARIANCE OR CU"77777E OR ADB# I INSPECTION BOND
REO'D POSTED
[1YES ONO IS
SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP I
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LOT COVERAGE
REQUIRED SETBACKS (Fr.)
PROPOSED SETBACKS (FT)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT IJR SIDE REAR
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PARKING
LOT AREA
PLANNING REVIEWED BY DATE
REO'D I PROVIDED
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REMARKS
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CHECKED BY JW OF 0 S1RUjTrj, 4COPE OCCUPANT
GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED E] YES I LOAD
REMARKS 0
PROGRESS INSPECTIONS PER UBC 108/ IBC109/ IRC109 FINAL INSPECTION REQaj'D
VALUATION
$ /')1 —7/ L
MT�
Descrintion FEE
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
Description FEE
State Surcharge
City Surcharge
Base Fee
7-T7 It I I
Plan Chk. Deposit
C:�) Receipt #
Ar� - Q 5 7J
CALL
FOR INSPECTION
(425)
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771-024116.11
Total Amt. Due
Receipt # tl 0
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.
FFICJALS SIGNATURE VAI E
A17ENTION EXT 1333 IL
ITIS 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 COPI
ORIGINAL - FILE
PINK - OWNER
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YELLOW - INF3PECTO
GOLD -ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE 16 _Z_ (e 4_�
PLCA%C STUN
ENGINEERING DIVISION DATE
PLEASE SIGN
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PLANNING DIVISION DATE
PLEASESIGN
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PROJECT S7_��VS_AA
SITEADDRESS 601 ?6 149- L/0_
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PERMIT# 910,0q — ADB# DATE INSPECTED. (J 67e
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DESCRIPTION OF WORK TO BE INSPE CTED
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A field inspection was conducted to determine compliance with -approved plans. Final approval
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denotes that there are no objections from the above signed Department to the release of
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PERFORMANCE BONDS and the granting of:
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GRANT FINAL PROJECT APPROVAL
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GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
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0 Copy of CONDITIONS given to owner/contractor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
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1:1 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
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RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signature
1: tenip:bldg: forms: ocaprvi 3/25/04
I
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 APPROVALW
..................
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