20041014.pdfDATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
MAILING ADDRESS
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CITY ZIP TELE
,PHONE
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NAME
ADDRESS
CITY ZIP I TELEPHONE
NAME `1 CBL # I,
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ADDRESS
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ZIP
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STATE LICENSE NUMBER EXPIRATION DATE CH CKER BY
PROPERTY TAX ACCOUNT PARCEL NO.
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NEW
RESIDENTIAL
PLUMBING / MECH
ADDITION
COMMERCIAL
COMPLIANCE OR
CHANGE OF USE
REMODEL
MULTIFAMILY
SIGN
REPAIR
GRADING CYDS
Ei
FENCE X FT)
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DEMOLISH
M
TANK
F-1
OTHER
oGARAGE
CARPORT
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RETAINING WALL
ROCKERY
1:1
FIRE SPRINKLER
FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN: n
M NUMBER NUMBER OF
0 OF DWELLING
M
0 STORIES UNITS
DESCRIBE WORK TO BE DONE
Iff", Virz) SLID
SOURCE
PLAN CHECK NO:
K
CRITICAL
AREAS
NUMBER
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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: 160 DAYS
PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
OAPPLICANT, 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 LA13OR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
E (OWN M I DATE SIGNE
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ADDRESE 1101107
PLAT NAM E/SU BDIVI SION NO.
PERMITEXPIRES LC�Z,ZIZ'
PERMIT
NUMBER
I � �, ;*1 SUITE/APTk
A?v
LOT NO LID NO
LID FEE S
I ESCP Approved 13
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
RW Permit Required 13
Street Use Pound Roq'd E3
EXISTING - PROPOSED
Inspection Required
Sidewalk Required
REQUIRED DEDICATION- Fr
Underground
Wiring requited
METER SIZE
LINE SIZE
NO. OF FIXTURES
I
PRV REQUIRED
I
YES 1:1 NO 1:1
REMARKS
OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
ENGINEERING
FIRE REVIEWED BY
VARIANCE OR CU
SEPA REVI EW
UUMI'LIMIt EXEMPT
EXP I
LOT COVERAGE
ALLOWED PROPOSED
DATE
117011;
SHORELINE OR ADBM INSPECTION -BOND
REOO POSTED
OYES ONO IS
SIGN AREA HEIGHT
FALLOWED . PROPOSED I ALLOWED . PROPOSED
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REQUIRED SETBACKS (Fr.) PROPOSED SETBACKS (Fr.)
FRONT SIDE REAR FRONT LIR SIDE REAR
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PARKING LOT AREA I PLANNING REVIEWED BY DATE -3
REO'D I PROVIDED I a.
REMARKS
CHECKED BY TYPE OFj CONSTRUCTION OCCUPANT
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SPECIAL INSPECTION ]AREA OCCUPANT
REQUIRED [] YES LOAD
REMARKS z
PROGRESS INSPECTIONS PER UBC 108/ IBC109/ IRC109 FINAL INSPECTION REO'D__ �
VALUATION
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapeinsp.
Recording Fee
CALL
FOR INSPECTION
FEE Description FEE
State Surcharge
City Surcharge
Base Fee &trj
0
(425)
771-0220 R
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt # -`0
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.
56bIALS SIGNATURE - DATE
XffENTION LA I 1;j;j;j
ITIS UNLAWFULTO USEOR OCKIP111YABUILDING OR STRUCTURE UNTILAFINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCU-
PANCY HAS BEEN GRANTED. UBC109/IBC110/IRC110.
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
:91
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 ....................
GasPiping .................
Equipment
.................
Commercial Final .......
EXTERIOR SHEATHING
NAILING ..........................
FRAMING ........................
FIRST FL60R FRAMING ...
INSULATION ...................
Flo6r Insulation .........
Wall Insulation ...........
Ceiling Insulation .......
SHEETROCK NAILING ...
SPECIAL INSPECTION ...
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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The lilitials-MT are Milton
nionvson, a temporary contract
inspector ror tile City.
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