20040942.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAMEINAME OF BUSINE5S_.,
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CITY
NAME
ADDRESS
CITY
NAME
ZIP
ZIP
TELEPHONE
47-5.-
TELEPHONE
8 -
CBL #
ADDRESS 4
1 5 +
3 5
CITY ZIP ELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE __5�M�N BY
PROPERTY TAX ACCOUNT PARCEL NO
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NEW
RESIDENTIAL
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PLUMBING / MECH
ADDITION
02�MERCIAL
COMPLIANCE OR
CHANGE OF USE
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REMODEL
MULTIFAMILY
SIGN
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REPAIR
GRADING
CYDS
FENCE
( X F-0
DEMOLISH
TANK
OTHE.
GARAGE
RETAINING WALL
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FIRE SPRINKLER
CARPORT
ROCKERY
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXP41N
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NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS
M 0 STORIES NUMBER
DESCRIBE WORK TO BE DONE
HEAT SOURCE GLAZING % I LOT SLOPE %
PLAN CHECK NO: I VESTED DATE
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1 PERMIT EXPIRES �:;q t LZ I L
USE PERMIT
ZONE NUMBER
JOB
SUITE/APT#
ADDRESS
PLAT NAMEISUBDIVISION NO. LOT NO,
LID NO.
LID FEE $
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
1ESCP Approved
RW Permit Required
13
13
Street Use Permit Roq'd
E3
EXISTING — PROPOSED
Inspection Required
13
Sidewalk Required
E3
REQUIRED DEDICATION— FT
Underground
Wiring required
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YES13 NO 1:1
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REMARKS
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OWNER/CONIRACTOR RESPONSIBLE FOR EROSION CONTROWDRAINAGE
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ILL!
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
It= 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 100 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
cn 'APPLICANT ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
q IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOID HARMLESS THE CITY OF
2 EDMONDS, WASHINGTON. ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
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4 ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
x FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF 1111S PERMIT SHALL NOT BE
0 - OF ANY CITY ORDINANCE
_j DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMEN I
0 NOR LIMIT IN ANY WAY THE Cl rYS 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 DU& 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 VI'6LATION OF THE LABOR CODE OF -THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATIO RANCE AND RCW 18.27.
DATE SIG�ED
SIGNATURE 71MWNE_a 10 G T
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
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VARIANCE OR CU
SHORELINE OR ADB#
i INSPECTION
BOND
REQ;r,
POSTED
I
11YES 4��NNO
S
SEPA REVIEW
SIGN AREA
HrziGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED PROPOSED
EXP
LOT COVERAGE
REQUIRED SETBACKS (FT)
PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT L1R SIDE REAR
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PARKING
L8T AR A
I PLANNING REVIEWED 13Y DATq
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REMARKS
CHECKED BY ITY 7
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Pfq OF GO �CTIO CODE,�) OCCUPANT
GROUP
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SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [] YES LOAD
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PROGRESS INSPECTIONS PER UBC 108/ IBC109/IRC109 FINAL INSPECTION RECI'D 5
VALUATION
$ 1 13LI
Descriotion FEE
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
CALL
FOR INSPECTION
0
(425)
771-0220
Description
FEE
State Surcharge
4,5-0
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due 5q� It 11GC
I Receipt # I
APPLICATION APPROVAL
I his application is not a pennit until signed by the
Building Official or his/tier Deputyi and Fees are paid, and
receipt is acknowledged in space provided.
-FICIALS SIGNATURE DATE
"/ --\) 0/0/0
:IF A,�WID HY/ j___1 / DATE I
A17ENTION t)k I I
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE ANDAPPROVALOR A CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/18CI10/]RCIIO.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Foo'tin'
9 ......................
Wall..........................
Pier/Porch ................. z
0
--I
Retaining Wall ...........
1711
Slab Insulation ..........
PLUMBING: =n-
Underground ............. 0 ITI
M 0
Rough -In ................... 0
0
0
Commercial Final ...... C
M
HEATING: M Z
GasTest .................... C
Gas Piping .................
Equipment ................. 0 -n
Commercial Final .......
M M
EXTERIOR SHEATHING
NAILING .......................... 0 r-
0 ITI
C Cn
FRAMING ........................
M 0
FIRST FLOOR FRAMING ... Z
INSULATION ...................
Floor Insulation ......... >
z
Wall Insulation ........... --I
Ceiling Insulation ....... Cn
z
0
SHEETROCK NAILING ... I
SPECIAL INSPECTION ... 1711
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY .................. Lp - o4-