0629_001.pdf'nc. 18'>"
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: http://www.edrnondswa.gov/
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address:
Parcel
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER: /
�- Name:
ailing Address:
c� p
City/State/Zip:
Phone #:
OWNER INSTALLATION:`*If yes, read)and sign*
Will work be performed by the p owner? El Yes ❑ No
1 own, reside in, or will r e in a completed structure.
This installation is b�g made on property that I own which is
not intended for sale, lease, rent, or exchange according to
RCW 18.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant:
Mailing Address: _
City/State/Zip:
Phone #:
E-mail:
GENERAL CONTRACTOR. i;nif�ent from licant)
`_ 11 C
General Cbrrtractor:'�l.\D
Mailing Address:
City/State/Zip: _
Phone #:
E-mail:
WA STATE CONTRACTOR L & I # (CCB) & EXPIRATION DATE:
=t#:
❑ Accessory Structure/
❑ Addition
Detached Garage
❑ Demolition 1 ❑ Mechanical
❑ New Single Family / Duplex IPlumbing
❑ Fire Sprinkler El Remodel
❑ New Commercial/ Mixed Use 1 ❑ Re -Roof
❑ Signs 1 ❑ Tank
❑ Tenant Improvement I ❑ Other
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (rounded to
the nearest dollar) of all equipment, materials, labor, overhead,
and the profit for the work indicated on this application.
Valuation:
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
I certify that the information I have provided on this form/application is true,
correct and complete, and that I am the property owner or duly authorized
agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name:
CITY OF EDMONDS BUSINESS LICENSE #: I Signature: Date
GENERAL• DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction:
Fire Sprinklers: Yes ❑ No ❑
WA STATE ENERGY CODE: If your project affects the building envelope,
mechanical systems, and/or lighting, you must complete the
appropriate WSEC forms.
DEFERRED SUBMITTALS: All commercial building permits that will require
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet
EQUIPMENTMECHANICAL •
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE .. re -piped)
Qty Qty
Clothes Washer
Tub/ Showers
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
Water.Heater -Tankless? Y or N
�-
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
GAS/FUEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ / Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace Other:
COUNTSMEDICAL GAS, AIR VACUUM
.. re -piped)
Qty
Qty .
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum Other:
DEMOLITION
Type of structure to be demolished:
Square footage of structure to be demolished:
AHERA Survey done? Y / N PSCAA Case #:
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material:
Removal ❑ Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
•..
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
GENERALPROVISIONS
APPLIC IONS: Applications are valid for a maximum of 1 year.
ESLHA Ap lications, 2 years.
,L C NG: All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & Industries and have a
current City of Edmonds Business License.