20040883.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY P_ TELEPHONE
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NAME
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CITY
ZIP [TELEPHONE
NAME CBL4
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COMPLIANCE OR
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SIGN
REPAIR
GRADING
CYDS
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FENCE
( X FT,
DEMOLISH
TANK
OTHER
GARAGE
CARPORT
RETAINING WALL
ROCKERY
FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS O"CTIViTY) 9PLAIN
NUMBER
OF
STORIES
NUMBER OF
DWELLING
UNITS
CRITICAL
AREAS
NUMBER ti")1A
DESCRIBE WORK TO BE DONE
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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: 180 DAYS
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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
M EDMONDS, WASHINGTON. ITS OFFICIALS. EMPLOYEES, AND AGENTS FROM ANY AND
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
9 DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITY'S 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 LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S CpWIRN�ATION INSURANCE AND RCW 11127.
DATE SIGNED
X
PERMITEXPIRES
UTE
ZONE
PERMIT
NUMBER
JOB
SUITE/APT#
ADDRESS
PLAT NAME/SUBDIVISION NO. LOT NO.
LID NO.
LID FEE $
TESCP Approved
11
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required
13
Street Use Permit Rnq'd
13
EXISTING -
PROPOSED
inspection Required
Sidewalk Required
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13
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FIRE REVIEWED BY uj
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VARIANCE OR CU I S1Wftyh1KajyCj IN5PLIL111114
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SEPA REVIEW
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ALLOWED PROPOSED
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AILOWED PROPOSED
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LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FF.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LIFISIDE REAR
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PARKING
LOT AREA
13Y DATE
PLANNING REVIEWED By IL
REQ'D I PROVIDE�D
REMARKS
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SPECIAL INSPECTION JAREA OCCUPAIN I
REQUIRED [] YES LOAD
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PR 0 "RES, S, 111,13PEC11ONS PER UBC 108/ ISC109/ IRC109 FINAL INSPECTION REQ'D J 9
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
CALL
FOR INSPECTION
(425)
771-0220
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt # 2-4:;P
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.
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FACIAL i IGOAI URE ly
S
FtFASED.BY I DATEF
A17ENTION Wk I I jjj
ITIS UNLAWFULTO USE OR OCCUPYA BUILDING 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
OFAIC31NAL - FILE YELLOW - INSPECTOR
PINK OWNER GOLD -ASSESSOR
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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 .................. Ad —.21 9/_ 64
The initials Ware Milton
Thonipsoll, 'I temporary contract
Illspectol- fol- tile City.
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