20041071.pdfN
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F�ATE RECEIVED
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
OWNER NAME/NAME OF BUSINESS
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MAILING ADDRESS
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CITY ZIP TELEPHONE
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NAME
ADDRESS
CITY
ZIP ITELEPHONE
NAME
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ADDRESS
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CEIL 4
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CITY ZIP TELEPHONE
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STATE LICENSE NUMBER EXPIRATION DATE
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PROPERTY TAX ACCOUNT PARCEL NO
NEW
RESIDENTIAL
ADDITION
COMMERCIAL
El
REMODEL
MULTIFAMILY
REPAIR
GRADING CYDS
DEMOLISH
TANK
EiGARAGE
CARPORT
RETAINING WALL
ROCKERY
(TYPE OF USE, BUSINESS OR ACTIVITY) EXPLAIN:
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PLUMBING / MECH
COMPLIANCE OR
CHANGE OF USE
SIGN
FENCE
( X FT]
OTHER
SPRINKLER
EFIRE
I
FIRE ALARM
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1151 ?,g_4 Le tu
w NUMBER NU�BER 00 CRITICAL
0 OF DWELLING AREAS
Ce UNITS
0 STORIES NUVBER
DESCRIBE WORK TO BE DONE ? W/z—
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HEAT SOURCE I GLAZING % I LOT SLOPE %
PLAN CHECK NO: I 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. 1 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 DIRECTtY OR INDIRECTLY
FROM THE ISSUANCE OF THIS PERMIT ISSUANCE OF THIS PERMIT SHALL NOT RE
DEEMED TO MODIFY. WAIVE OR REDUCE ANY REQUIREMENT OF ANY CITY ORDINANCE
NOR LIMIT IN ANY WAY THE CITYS ABILITY TO ENFORCE ANY ORDINANCE PROVISION."
PERMIT EXPIRES
S E
USE PERMIT
0 N E
ZONE N U M B E R
�,9 71
13
JOB
0
SUITE/APT#
0 D R F S
ADDRESS 12
M E S U E
PLAT NAMEISUBDIVISION NO.
L T A
P A N
LOT NO.
LID NO.
LID FEE S
HT' 0 F
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
P U B L IC R IG
7ESCP APPf0v0 d
BW Permit Required
13
13
Street Use Permit Sort'd
(3
E X I
XISTING PROPOSED
inspection Required
Sidewalk Required
13
EQUIRED DEDICATION— FT
R 0 D C
Underground
wiring required
0
METER SIZE
LINE SIZE
NO. OF FIXTURES
PRV REQUIRED
YESED NO
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REMARKS
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OWNEF /CONTRACTOR RESPONSIBLE FOR EROSION CONTROL/DRAINAGE
OW I/CONTR C
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 COMPENSATION INSURANCE AND RCW 18.27.
DATE SIGNED
ENGINEERING REVIEWED BY
FIRE REVIEWED BY
VARIANCE OR CU
SEPA REVIEW
COMPLETE I EXEMPT
EXP
LOT COVERAGE
ALLOWED PROPOSED
DATE
DATE W
M
U.
SHORELINE ORADB# INSPECTION BOND
REO'D POSTED
OYES ONO S
HEIGHT
SIGN AREA I
TALLOWED . PROPOSED ALLOWED , PROPOSED
REQUIRED SETBACKS (FT) PROPOSED SETBACKS (Fr.)
FRONT SIDE REAR FRONT URSIDE REAR
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PARKING LOT AREA LANNING REVIEWED BY DATE
REO'D I PROVIDED I r
REMARKS
CHECKED BY
N C(IDE OCCUPANT
GROUPC
10,17 _4
SPECIAL INSPECTION JAREA OCCUPANT
REQUIRED [:] YES LOAD
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PROGRESS INSPECTIONS PER UBC108/IBC1091IRC109 FINALINSPECTION REO'D
M A R 0' H A L to
RESENT FOR
r�p,in\'AL UR C/.\P
VALUATION 14INK FILL r , lk.*v .
Description
Plan Check
Building Permit
Plumbing
Mechanical
Grading
Engr. Review
Engr. Inspection
Fire Review
Fire Inspection
Landscapelnsp.
Recording Fee
CALL
FOR INSPECTION
(425)
FEE Description FEE
State Surcharge
City Surcharge
Base Fee
Plan Chk. Deposit
Receipt #
Total Amt. Due
Receipt # =9
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.
Fihmi s qLr.NATU`1RE DATE
771-0220
A AT_rg=MT1I
TTENTION E)ff 1333
IT IS UNLAWFULTO USE OR OCCUPYA BUILDING OR STRUCTURE UNTILA FINAL
INSPECTION HAS BEEN MADE AND APPROVAL ORA CERTIFICATE OF OCCLI-
PANCY HAS BEEN GRANTED. UBC109/IBC110/lRC110-
09/03 PRESS HARD -YOU ARE MAKING 4 COPIES
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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:
GasTest ....................
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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