20040993.pdfDATE RECEIVED � 2"'11
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
ER NAMEINAME OF BUSINESS
MAILING ADDRESS
CITY ZIP TELEPHONE
F 11
D1111 (W . it ,
NAME
ADDRESS
TELEPHONE
Cal #
PERMIT WC
NUMBER
JOB
ADDRESS
PLAT NAMEiSUBDIVISION NO
PERMIT EXPIRES
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;? SUITE/APT#
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LOT NO LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCPApproved W
RVV PrifWA RoqulfW . 0
Street use Ptirma Requirea 0
EXISTING .-PROPOSED In5pection Required 13
SKjawali, Required 0
REQUIRED DEDICATION FT underground C3
I Mnnq rPquiled
METER SIZE LINE SIZE NO, OF FIXTURES I PRV REQUIRED
YES13 NOO
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
ENGINEERING REVIEWED BY DATE
-.4 LAVI li..01 0c,
-t�2' M1 I FIRE REVIEWED BY DATE
CITY ZZiP I TELEPHONE
BY
STATE LICENSE NUMBER EXPIRATION DATE CHECKED
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PROPERTY TAX ACCOUNT PARCEL
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ADDITION COMMERCIAL C E OR
E] MIXED USE CHANGE OF USE
REMODEL MULTIFAMILY SIGN
GRADING FENCE
REPAIR CYDS ( X FT.)
DEMOLISH TANK OTHER
GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPL/�,X)
NUMBER NUMBER OF
OF DWELLING
STORIES I I UNITS
DESCRIBE WORK TO BE DONE
HEAT SOURCE I LOT SLOPE% I VESTED DATE
PLAN CHECK NO:
THIS PERMIT AUTHORIZES ONLY 1HE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
*APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
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 MODIFY, WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
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
WORKMENI��SATION INSURANCE AND RCW 18:27.
SIGJ�ATUR4 OV AG T):
VNER; DATE SIGNED
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VARIANCE OR CU SHORELINE OR ADIIII I INSPECTION SEPA
RECI'D COMPLETED EXEMPT
13YES [3 NO I I
CA# ZONE SIGN AREA HEIGHT
WAIVER 13 ALLOWED , PROPOIED ALLOWED , PROPOSED
STUDY [3 1
LOT COVERAGE REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.)
ALLOWED PROPOSED FRONT SIDE REAR FRONT L/RSIDE REAR
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PARKING LOTAREA PLANNING REVIEWED BY DATE
REQ-0 . PROVIDED I I IL
REMARKS
SPECIAL INSPECTION
REQUIRED [3 YES
REMARKS
GEOTECH REPORT
BY:
STRUCTURAL DESIGN
BY:
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
LandscapeInsp
Recording Fee
OCCUPANT
GROUP
CONSULTANT OCCUPANT
I LOAD
CALL
FOR INSPECTION
(425)
771-0220
ATTENTION .40, EXT. 1333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTI-
FICATE OF OCCUPANCY HAS BEEN GRANTED. UBC109 If IBC110 / IRC110.
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt #
APPLICATION APPROVAL
This application is not a permit until signed by the
Building Official or histher Deputy and Fees are paid.and
receipt is acknowledged in space provided
OFFlCIALSj6jGt)APRE — DATq
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RELEASED BY
10104 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 .............
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 .................. '14
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The Initials MT arc Miltion
Thompson, a temporary contract
inspector for the City.
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