20040909.pdfDATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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STATE LICENSE NUMBER
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NEW
ADDITION
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REPAIR
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RETAINING WALL
ROCKERY
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NUMBER NUMBER OF
OF DWELLING
STORIES UNITS
DESCRIBE WORK TO BE DONE
HEAT SOURCE I GLAZING %
PLAN CHECK NO:
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COMPLIANCE OR
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PERMIT EXPIRES
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PLAT NAME/SUBDIVISION NO.
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LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
I ESCP Approved
RW Permit Required
Street Use Permit Roq'd
EXISTING — PROPOSED
Inspection Required
sidewalk Required
REQUIRED DEDICATION—
FT
Underground
Wiring required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES 1:1 NO 0
REMARKS
OWNER/CONTRACTOR RES PONS I B ��E9B_kaQ,5JJQNfAQU12=
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ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
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SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP ,
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LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (F-0
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT LJR SIDE REAR
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PARKING
LOT AREA
PLANNING REVIEWED BY DATE
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AREAS SPECIAL INSPECTION IA'RtA OCCUPANT
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PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REO'D
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THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
t BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
W PERMIT APPLICATION: 180DAYS
It. 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
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
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
21 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 COMPENSATION INSURANCE AND RCW 18 27.
(OWNER OR
VALUATION
Description FEE Description FEE
Plan Check State Surcharge
Building Permit City Surcharge
Plumpjn�.
Vchanical
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Engr. Review
Engr. Inspection
Fire Review Plan Chk. Deposit
Fire Inspection Receipt ft
Landscape Insp. Total Amt. Due
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Recording Fee Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
CALL Building Official or his/her Deputy: and Fees are paid, and
FOR INSPECTION receipt is acknowledged in space provided.
(425) VIC)l SIC�!ATURE - 'IT E
771 -0220
RELIfSED BY Alrd
A1qENTION )ff 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
DATE SIGNED
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ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
GREEN ACCOUNTING
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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 ..................
The initials MT are Miltoil
Thompson, a temporary contract
inspector for the City.
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