20041089.pdfDATE
CITY OF EDMONDS
CONSTRUCTION PERMIT APPLICATION
,�'NER NAMEiNAME OF BUSINESS
WX MAILING ADDRESS
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NAME
ADDRESS
PHONE
NAME 1CBL#
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ADDRESS
CITY ZIP TELEPHONE
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STATE 4tENSE NUMBER EXPIRATION DATE CHECKED BY
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PROPERTY TAX ACCOUNT PARCEL NO
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PERMIT EXPIRES
PERMIT
NUMBER Z,
JOB
ADDRESS
SUITE/APT#
PLAT NAM E/S UB DIVISION NO
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LOT NO
LID NO
LID FEE S
PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP
IESCPApprovpd
13
El
RW Permit Required
13
EXISTING PROPOSED
Street Use Permit Required
inspection Requited
0
Sidewalk RoquireJ
13
REQUIRED DEDICATION FT
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undeigiound
1,1VInIq n-milfed
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METER SIZE
NO, OF FIXTURES
PRV REQUIRED
YESO NOO
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REMARKS
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OWNERICONTRACTOR RESPONSIBLE FOR EROSION CONTROLIDRAINAGE
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ENGINEERING REVIEWED BY
DATE
FIRE REVIEWED BY DATE W
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VARIANCE OR CU SHORELINE OR ADB# I INSPECTION SEPA
REQ'D COMPLE
113YES 13NO
CA# ZONE SIGN AREA HEIGHT
1A1A1%1C0 [:] ALLOWED . PROPOSED I ALLOWED . PkOPOSLD
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STUDY 13
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El PLUMBING / MECH
LOT COVERAGE
ALLOWED PROPOSED
ADDITION
COMMERCIAL COMPLIANCE OR
_OR
1:1 USE
CHANGE OF
MIXED USE
REMODEL
MULTIFAMILY SIGN
PARKI
REQ'D
I PEE
REPAIR
GRADING FENCE
CYDS X FT.)
REMARKS
DEMOLISH
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TANK OTHER
GARAGE
RETAINING WALL FIRE SPRINKLER
CARPORT
ROCKERY FIRE ALARM
YPE OF USE. BUSINESS OR ACTIVIT.Y) EffLAIN.
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TYPE Or CONST U TIO1
NUMBER
NUMBER OF
OF
STORIES
OWE[ - LING
UNITS
SPECIAL IV16PECTION
REQUIRED 13YES
DESCRIBE WORK TO BE DONE
A- U
REMARKS
GEOTECH REPORT
BY
STRUCTURAL DESIGN
BY:
VALUATION
REQUIRED SETBACKS (FT) PROPOSED SETBACKS (FT.)
FRONT SIDE REAR FRONT LIR SIDE REAR 0
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LOT AREA I PLANNING REVIEWED BY DATE 5
DE OCCUPANT
GROUP x
CONSULTANT CCUP�NT
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Description
FEE
Description
FEE
State Surcharge
City Surcharge
Plan Check
HEAT SOURCE
LOTSLOPE%
VESTED DATE Building Permit
PLAN CHECK NO-
Plumbing
Base Fee
Mechanical
THIS PERMIT AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVERS WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBIC Grading
DONMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
0
SEPARATE PERMISSION.
Engr Review
PERMIT APPLICATION: SEE ECDC 19.00.005(A)(5)
PERMIT LIMIT: SEE ECDC 19.00.005(A)(6)
Engr Inspection
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
-APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HEIRS, ASSIGNS AND SUCCESSORS
J hk. Deposit
Fire Review Plan C
IN INTEREST, AGREES TO INDEMNIFY, DEFEND AND HOLD HARMLESS THE CITY OF
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
Fire Inspection
Receipt #
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE. ARISING DIRECTLY OR INDIRECTLY
FROM THE ISSUANCE OF T141S PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
Landscape Insp
Total Amt. Due 4�
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.'
T_
Recording Fee
Receipt #
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION; THAT THE INFORMATION
APPLICATION APPROVAL
GIVEN IS CORRECT; AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
Thi5application i% net a pohnit until signed by the
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC.
CALL
Building Official cif hisiher Deputy and reusare paid, and
TION; AND IN DOING THE: WORK AUTHORIZED THEREBY. NO PERSON WILL BE EMPLOYED
IN VIOLATION C"1E LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
FOR INSPECTION
receipt isacknowled(ed in space provided
9
WORK ME N'S'COM 17N SAT 10 INSURANCE AND RCW 18:27.
OFFIqIALS SIGNATURE' DATE
SIGN TU low DATE SIGNED
177t
(425)
� 0-21't
1
771-0220
- /)ATE f
F TFU�F �'LD BY
ATTENT13N 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 / IBC110 / IRC110.
110104 PRESS HARD - YOU ARE MAKING 4 COPIES
F P'llil 191(XI-91 11,1/
ORIGINAL - FILE YELLOW - INSPECTC
PINK - OWNER GOLD - ASSESSOR
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FINAL PROJECT APPROVAL FORM
TO:
DATE:
MEMO TO: PERMIT COORDINATOR, BUILDING DIVISION
FROM: FIRE, DEPARTMENT DATE --,--
PLEASE SIGN
ENGINEERING DIVISION DATE
PLEASE SIGN
PLANNING DIVISION DATE
PLEASESIGN
PROJECT e' e-)IL,112 cT I
SITE ADDRESS— P/- Ah�
PERMIT #1 16,t ADB# DATE INSPECTED—q--/
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:
GRANT FINAL PROJECT APPROVAL
GRANT PROJECT APPROVAL WITH CONDITIONS NOTED
Copy of CONDITIONS given to owner/contractor by inspector
FAILED FINAL INSPECTION - OUTSTANDING ISSUES
0 Copy of CORRECTION NOTICE given to owner/contractor by inpector
2.
3.
R-E-INSPECTED OUTSTANDING ISSUES - GRANT FINAL PROJECT APPROVAL
Date SignatUre
I:teiiip:bldg:foi-tils:oc-,il)rvI 3/25/04
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RECORD OF INSPECTIONS
INSPECTOR DATE APPROVED
SETBACKS .....................
FOUNDATION:
Footing .. ...................
Wall....... ..................
Pier/Porcl- .................
Retaining fiall ...........
Slab Insul3tion ..........
PLUMBING:
Undergroi nd .............
Rough -in ...................
Commerc al Final ......
HEATING:
Gas Test ....................
Gas Pipir g .................
Equipment .................
Commercial Final .......
EXTERIOR SHEATHING
NAILING.... .....................
FRAMING .. .....................
FIRST FLOOR FRAMING ...
INSULATIO� ...................
Floor Insulation .........
Wall Ins ilation ...........
Ceiling I isulation .......
SHEETROC< NAILING ...
SPECIAL IN,SPECTION ...
MISCELLA1,1EOUS ..........
FINAL APPROVAL FOR
OCCUPANCY ..................
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