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DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAMJE OF BUSINESS
MAILING ADDRESS
CITY Z(P_j TELEPHONE
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NAME
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CITY ZIP TELEPHONE
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NAME
ADDRESS
CITY ZIP TELEPHONE
,,,, 1 102 1 �41,% C�_ 7'
STATE LICENSE NUMBER
A A _01 .
PROPERTY TAX ACCOUNT PARCEL NO.
NEW
1:1
RESIDENTIAL
ADDITION
K—COMMERCIAL
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
GARAGE
rAPPORT
RETAINING WALL
ROCKERY
(TYPE OF USE, BUSINESS OA ACTIVITY) EXPLAIN:
CBL N
10
PLUMBING / MECH
COMPLIANCE OR
USE
CHANGE OF
SIGN
FENCE
( X. Fr
OTHER
rfjO FIRE SPRINKLER
N
tu NUMBER BER OF CRITICAL
OF DUWMELLING AREAS
0 STORIES NUMBER
DESCRIBE WORK TO BE DONE
(i
HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK NQ: VESTED DATE
THIS PERMIT AUTHORIZES ONLY THLf WORK NOTED. THIS PERMIT COVERS WORK TO
t: BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
F DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
.j SEPARATE PERMISSION.
PERMIT APPLICATION: 180DAYS
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9L 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 INDEMNIF�� 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 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
0 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
GIV
fEN Ic AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
S CORRECT,
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 VI'OLATI N OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORK=& COMPEN54TION Pj�,URANgE AND RCW 18.27.
SIGNATff (OWZ,9lf G DATE SIGNED
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USE
ZONE
JOB
ADORES
PLAT NAME/SUBDIVISION NO.
PERMIT EXPIRES
PERMIT
NUMBERI
LOT
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
EXISTING - PROPOSED
REQUIRED DEDICA11ON- FT
METER SIZE I LINE SIZE I NO. OF FIXTURES
SUITE/APT#
r
LID NO.
LID FEE $
TESCP Approved
RW Permit Required
Street Use Permit Req'd
inspection Required
Sidewalk Required
Underground
Witing required
PRV REQUIRED
YES 13 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
REVIEWED BY
OR CU
SEPA REVIEW
COMPLETE , EXEMPT
EXP
LOT COVERAGE
ALLOWED PROPOSED
DATE
DATE
/ () / 7- 6 /0'
lOtLINEORADBI I INSPECTION 6OND
REQ'D POSTED
OYES ONO IS
SIGN AREA HEIGHT
ALLOWED , PROPOSED I ALLOWED . PROPOSED
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REQUIRED SETBACKS (FT.) PROPOSED SETBACKS (Fr.)
FRONT SIDE REAR FRONT IJRSIDE REAR
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PARKING LOT AREA "NING REVIEWED BY DATE -3
91.
REO'D I PROVIDED
REMARKS
CHECKED BY ITYPE OF CONSTRUCTION CODE OCCUPAN
0: GROUP
JIJ4�� LOAD
SPECIAL INSPECT] )N AREA OCCUPANT
REQUIRED [:] YES,
REMARKS z
PROGRESS INSPEC11ONS PER UBC 108/IBC109/ IRC109 FINAL INSPECTION REQ'D g
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110
VALUATION
$ /� en�
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
Plumbing
Base Fee
5
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapelnsp-
Total Amt. Due
Al
Recording Fee
Receipt #
CALL
FOR INSPECTION
(425)
771-0220
APPLICATION APPROVAL
This application is not a permit until signed by the
Building ouicial or his/her Deputy: and Fees are paid. and
receipt is acknowledged in space provided.
OFF CIA IGNAT DATE
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R (E By I /IDATE
ATTE�MON E X T 13 3 3
IT IS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE U NTILA FINAL
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
ORIGINAL - FILE YELLOW -
PINK - OWNER GOLD - j
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FINAL PROJECT APPROVAL FORM
TO:
DATE: 6A o 0
MEMO TO: P CO R, BUILDING DIVISION
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FROM: 7e FIRE DEPARTMENT DATE 310f
PLEASESIGN
ENGINEERING DIVISION DATE
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PIAUE SIGN
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PLANNING DIVISION DATE
MXASP SIGN
PROJECT P4AIJ E�5'tf
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PERMIT#— 4 DATE INSPECTED
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DESCRIPTION OF WORK TO BE INSPECTED
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A Held inspection was conducted to determine final 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
PERFORMANCE, BONDS and the granting of
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GRANT PROJECT APPROVAL WrIH CONDITIONS NOTED
u Copy of CONDITIONS given to owner/contractor by inspector
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FAILED FINAL INSPECTION - OUTSTANDING ISSUES
c3 Copy of CORRECTION NOTICE given to owner/contractor by inspector
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Sign�
ocaprvl.doc.l:temp:bldg:formsIO/O1
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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