20040950.pdfI . ., .,I -
DATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS.
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MAILING ADDRESS
CITY ZIP
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NAME
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TELEPHONE
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STATE LICENSE NUMdER EXPIRATION DATE
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CBL 1$
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PROPERTY TAX ACCOUNT PARCEL NO.
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NEW RESIDENTIAL
PLUMBING / MECH
ADDITION COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL MULTIFAMILY
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SIGN
REPAIR GRADING
CYDS
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FENCE
( X FT)
DEMOLISH TANK
OTHER
GARAGE RETAINING WALL
CARPORT
FIRE SPRINKLER
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FIRE
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(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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NUMBER
NUMBER OF
CRITICAL
OF
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STORIES
UNITS
NUMBER
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PLAN CHECK NO: - , I � I . 16 1 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
2 DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
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SEPARATE PERMISSION.
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W PERMIT APPLICATION: IGO DAYS
IL PERMIT LIMITI YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
to 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS. ASSIGNS AND SUCCESORS
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9 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 HE
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_j DEEMED TO MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
701 NOR LIMIT IN ANY WAY THE CITYS ABIL11-Y 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 COMPENSATIC)K^-RANCE AND RCW 18 27.
SIGNATURE (OWNER OR E T)
DATE SIGNED
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PERMIT EXPIRES"711W-E-2
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USE PERMIT
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PLAT NAMEISUBDMSION NO,--
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LID NO.
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LID FEE $
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
7ESCP Applo�ed
RW Permit Required 0
Street Use pomil Req'd [3
EXISTING - PROPOSED
inspection Required E3
Sldewal� Required [3
REQUIRED DEDICATION� FT
Underground
wiring required
METER SIZE
LINE SIZE
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NO. OF FIXTURES
PRV REQUIRED
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YES13 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY DATE
FIRE REVIEWED BY DATE
RIANCE OR CU
HORELINE OR ADEIII
INSPECTION
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BOND
REC�D
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POSTED
E]YES P�NO
IS
SEPA REVIEW
SIGN AREA
HEIGHT
COMPLETE EXEMPT
ALLOWED PROPOSED
ALLOWED
PROPOSED
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EXP
LOT COVERAGE
REQUIRED SETBACKS (FT.)
PROPOSED SETBACKS (FT)
ALLOWED PROPOSED
FRONT SIDE REAR
FRONT
LiRSIDE REAR
PARKING
LOT AREA
PIANNING REVIEWE Y
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DATE
REO:_4_:ROVIDED
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CHECKEDBY I TYPE rFAC ;PFIUCTION I CrQEA OCCUPANT
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SPECIAL INSPECTION JAREA OCCUPANT�/
REQUIRED r7I YE I LOAD I
REMARKS
PROGRESS INSPECTIONS PER UBC 108/ IBC109/IRC109 FINAL INSPECTION REQ'D
FEE Description
State Surcharge
City Surcharge
Base Fee
FEE
Plan Chk. Deposit
Receipt #
Total Amt. Clue
Receipt #
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.
OFFICIALS SIGNATURE DATE
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RE Y DATE
ATTWION EXT 1333 11
ITIS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVAL OR ACERTIFICATE OF OCCU- L41
PANCY HAS BEEN GRANTED. UBC109/IBC110/IRC110.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
VALUATION
$ Lt --� 5 0 0 a
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscape Insp.
Recording Fee
CALL
FOR INSPECTION
(425)
771-0220
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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 .................
YVI
9
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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