20040953A.pdfDATE RECEIVED 1 �.7
Ir CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF 13USINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
CITY ZIP ITELEPHONE
PERMIT EXPIRES
U USE PERMIT
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SUITE/APT#
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[ADDRESS
PLAT NAMEISUBDIVISION NO. LOT NO.
LID NO.
LID FEE $
TIESCP Approved
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Raritered
Street uso Permit Reiri'd
EXISTING - PROPOSED
inspection Required
Sidewalk Required
REQUIRED DEDICATION- FT
underground
I Witingiertuvad
METER SIZE I
LINE SIZE
I NO. OF FIXTURES
PRV REQUIRED
YES 0 NO 0
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
NAME CBL0
L V F3 I x) ENGINEERING REVIE
ADDRESS ENGNEERNWGREVI E
-2 1 R V Y
FIRE REVIEWED BY
CITY ZIP TELEPHONE
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All�_) id 0/ T FL VARIANCE OR CU
RTATF I 1(-FN.qF: Nl lMfiFR EXPIRATION DATE QKFGKED BY
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NEW
ESIDENTIAL
ADDITION
COMMERCIAL
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
oGARAGE
CARPORT
RETAINING WALL
ROCKERY
(TYPE OF USE, BUSINESS OR ACTFVrI]0_qNWIN:
Ei NUMBER NUMBER 0
OF DWELLING
0 STORIES UNITS
DESCRIBE WORK TO BE DONE
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HEAT SOURCE I GLAZING %
PLAN CHECK NO:
SEPA REVIEW
C C
OMPLETE , EXEMPT
Dt EXP
LOT COVERAGE
ALLOWED PROPOSED
k(LU�M�BINECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
( X FT)
OTHER
FIRE SPRINKLER
FIRE ALARM
CRITICAL
AREAS
NUMBER
LOT SLOPE %
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
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
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 MODIF'� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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
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 COMPENSAT!9�;MW(IANCE AND RCW 18.27.
SIGnTURE (OWNER O� A tENT) DATE SIGNED
)`
DATE
DATE
SHORELINE OR ADIIII INSPECTION BOND
REO'D POSTED
OYES ONO S
SIGN AREA HEIGHT
ALLOWED , PROPOSED I ALLOWED , PROPOSED
REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (Fr.)
FRONT SIDE REAR FRONT UR SIDE REAR
PARKING LOT AREA I PLANNING REVIEWED BY DATE
REO'D I PROVIDED I
REMARKS
CHECKED BY __rE OCCUPANT
GROUP
SPECIAL INSPECTION VREA OCCUPANT
REQUIRED [:] YES LOAD
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PROGRESS INSPECTIONS PER UBC 108/IBC109/IRC109 FINALINSPECTION REO'D:
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
ATTENTION EXT 1333
IT IS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVALOR A CERTIFICATE OF OCCU_
PANCY HAS BEEN GRANTED. UBC109/IBC110/IRC110.
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt
Total Amt. Due ej, Z�17—
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 aCl�novvledged in space Provided.
FFIC141:S SIONAT0RE -n nATV
RELEASED
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
ORIGINAL - 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 .............
a
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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The Initials MT are Milton
1,11ollipson, a temporary contract
illspector for the CitY.
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