20041053.pdfDATE RECEIVED
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CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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LM MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
ADDRESS
CITY ZIP I TELEPHONE
NAME
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PERMITEXPIRES
FU USE PERMIT
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ZONE NUMBER
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OB SUITE/APT#
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PLAT NAMEISUBDIVISION NO. LOT NO. LID NO.
-7 LID FEE $
TESCP Approved 13
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP RW Permit Required El
street Use Parrn,, Roq'd E3
EXISTING - PF30POSED inspection Required
Sidawal� Required Ily
REQUIRED DEDICATION 10000� FT Undargiound
Winng required (3
METER SIZE LINE SIZE NO. OF FIXTURES PRV REQUIRED
NO
YES
REMARKS
[OWNER/CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
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ENGINEERING REVIEWED BY DATE
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ADDRESS
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FIRE REVIEWED BY DATE
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CITY ZIP
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TELEPHONE
VARIANCE OR CU
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PHORELINE OR ADBI I
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INSPECTION
REQ'D
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BOND
POSTED
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STATE LICENSE NUMBER EXPIRATION DATE
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CHECKED B
SEPA REVIEW
COMPLETE , EXEMPT
EXP JOL
SIGN AREA
ALLOWED , PROPOSED
HEIGHT
ALLOWED , PROPOSED
PROPERTY TAX ACCOUNT PARCEL NO.
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RESIDENTIAL PLUMBING/MECH
COMPLIANCE OR
ADDITION OMMERCIAL CHANGE OF USE
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GRADING FENCE
REPAIR CYDs ( x FT)
LOT COVERAGE
ALLOWED PROPOSED
REQUIRED SETBACKS (FT)
FRONT SIDE REAR
PROPOSED SETBACKS (FT.)
FRONT LJRSIDE REAR
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PARKING
REO'D I PROVIDED
LOT AREA
PLANNING REVIEWED BY DATE
REMARKS
DEMOLISH 1:1 TANK El OTHER
GARAGE RETAINING WALL FIRE SPRINKLER
CARPORT ROCKERY FIRE ALARM
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
CHECKED BY
ITYPE OF CIINSTRUCTION
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OCCUPANT
GROUP
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NUMBER
OF
STORIES
INUMBER OF
DWELLING
UNITS
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CRITICAL
AREAS
NUMBER
SPECIAL INSPECTION
REQUIRED
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JAREA
OCCUPANT
LOAD
DESCRIBE WORK TO BE DONE
REMARKS
PROGRESS INSPECTIONS PER UBC 108/FINAL INSPECTION REQ'D
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HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK 140: 1 1 VESTED DATE
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
I= BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
SEPARATE PERMISSION.
Lu PERMIT APPLICATION: 180 DAYS
IL PERMIT LIMIT I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
W 'APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESORS
13 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 BE
DEEMED TO MODIFY� WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
0 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 COMPENSATIO��IN RAN5�_�B RCW 18,27.
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SIGNATURE (OWNER 0 EN� DATE SIGNED
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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
A17ENTION E)ff 13 3 3
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI-
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109
FEE Description FEE
,�)/) — State Surcharge
1�4 � City Surcharge
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt III
APPLICATION APPROVAL
This application is not a permit until signed by the
Building ofticial or his/her Deputy: and Fees are paid, and
receipt is acknowledged in space provided.
TFIC,IALS SIGNA-ARE DATE
04/02 PRESS HARD -YOU ARE MAKING 5 COPIES
BY f UAIV
nal)
ORIGINAL - FILE YELLOW
PINK - OWNER GOLD - ASSESSOR
GREEN - ACCOUNTING
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE DEPARTMENT DATE
PLEASE SIGN
-- L W ENGINEERING DIVISION DATE_��
I Im ", 1/1
YPE AS E �IGIN
PLANNING DIVISION DATE
PLEASE SIGN
PROJECT A
SITE ADDRESS— 7)1 5_
PERMIT # 0 ADBA. DATE INSPECTED
DESCRIPTION OF WORK TO BE INSPECTED --
A field inspection was conducted to determine 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
Y GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
0 Copy of CONDITIONS given to owner/contractor by inspector
FAELED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
3.
RE -INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date Signattire
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing ......................
Wall..........................
Pier/Porch ................. z
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Retaining Wall ........... i I , . 11 .
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Slab Insulation ..........
PLUMBING: -1 -n
Underground .............
M
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Rough -In ................... 0
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Commercial Final ......
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M Z
HEATING: 1c) --I
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Gas Test .................... > z
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Gas Piping .................
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Equipment ................. n
Commercial Final .......
M M
EXTERIOR SHEATHING 0
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NAILING .......................... 0 M
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FRAMING ........................ U)�
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FIRST FLOOR FRAMING ... Z
INSULATION ................... W
Floor Insulation ......... >
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Wall Insulation ...........
Ceiling Insulation .......
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SHEETROCK NAILING ...
SPECIAL INSPECTION ... M
MISCELLANEOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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