20040971.pdfI
DATE RECEIVED /
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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UM MAILING ADDRESS
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CITY ZIP TELEPHONE
NAME
ADDRESS
CITY ZIP TELEPHONE
NAME CB7
ADDRESS
VE-
CITY ZIP I TELEPHONE
STATE LICENSE NUMBER
EXPIRATION DATE I CHECKED BY
PROPERTY) AC
27EZ1L
El
NEW
RESIDENTIAL
UMBING MECH
ADDITION
COMMERCIAL
PLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING
ryns El
FENCE
( X� FT,
DEMOLISH
1:1 TANK
o
OTHER
GARAGE
CARPORT
RETAININGWALL
El ROCKERY 1:1
FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE. BUSINESS OR ACTIVITY)__E�WIN:
NUMBER NUMBER OF CRITICAL
OF DWELLING AREAS ILI
STORIES UNITS NUMBER LV
DESCRIBE WORK TO BE DONE
1 4- 1/' 1 <.-
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HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK NO: VESTED DATE
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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: 1130 DAYS
W
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
M EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
x FROM THE ISSUANCE OF THIS PERMIT, ISSUANCE OF THIS PERMIT SHALL NOT BE
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j DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 NOR LIMIT IN ANY WAY THE CITY'S ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
USE
ZONE
JOB
ADDRESS /I//
PLAT NAME/SUBDIVISION NO
PERMIT EXPIRES A 1
PERMIT
NUMBER
- SUITE/APT#
y o'li-
7 LOT NO. LID NO.
LID FEE $
TIESCP Approved 13
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Perind Requiled
13
Street Use Permit Req'd
0
EXISTING — PROPOSED
Inspection Required
13
Sidewalk Required
13
HFOUIRED DEDICATION— FT
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Undieground
Winng required
0
METER SIZE
LINE SI"
NO. OF FIXTURES
PRV REQUIRED
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YES 13 NO 13
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING REVIEWED BY
DATE
6-oROAJE- 13 FLAb I L%.o r " " "'JAft * � — —
1PINOPROVIDED
WATERSERVIrEp
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CHECKED BY ITYPE
OCCUPANT
GROUP
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED YES LOAD
1 13
REMARKS z
1PROGRESS INSPECTIONS PER UBC 108 /IBC109 if IRC109 FINAL INSPECTION RE9D F2
I
VALUATION
Description
FEE
Description
FEE
Plan Check
State Surcharge
Building Permit
City Surcharge
Plumbing
Base Fee
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Plan Chk. Deposit
Fire Inspection
Receipt #
Landscapelnsp.
Total Arnt. Due
Recording Fee
Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFAORMATION - APPLICATION APPROVAL
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- [his application is not a permit until signed by the
LL I EMP CALL
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED Building Official or his/tier Deputy: and Fees are paid, and
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IN VIOLATION CISAJiE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO FOR INSPECTION receipt is acknowledged in space provided.
WORKMEN'S 99MPENsATION INSURANCE AND RCW 18.27.
I OFFICIALS SI.GNA:rUPE 9ATE
s G !ATURE 0 NE 6R- AGENT) DATE SIGNED (425)
771-0220
ATTENTION E)ff 1333
ITIS UNLAWFULTO USE OR OCCUPYABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE ANDAPPROVALOR ACERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/lBC110/1RC110.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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I DATE/
ORIGINAL - FILE YELLOW - INSPECTOR
PINK - OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: —FIRE DEPARTMENT DATE
MASE SM
ENGINEERING DIVISION DATE
.. I�E W.G.
PLANNING DIVISION DATE
nFASP SM
PROJECT— I Ll
SITE ADDRESS
PERMIT
�//��ADB# DATE INSPECTED
DESCRIPTION OF WORK TO BE INSPECTED
A field inspection was conducted to determine final compliance with approved plans. Final approval
denotes that there are no objections from the above signed Department to the release of
PERFORMANCE BONDS and the granting of:
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
o Copy of CONDITIONS given to owner/contractor by inspector
I .
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
o Copy of CORRECTION NOTICE given to owner/contractor by inspector
PA
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Sign_
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RECORD OF INSPECTIONS
INSPECTOR
DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall ..........................
Pier/Porch .................
Retaining Wall ...........
Slab Insulation ..........
PLUMBING:
Underground .............
Rough -In ...................
CV #ggNjwa+ Final ......
HEATING:
174/5 'F, 471
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 ..................
nic Initials NIT are Milton
Thompson, a temporary contract
ilispcctor for tile City.
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