1565_001.pdfc. I s9 o
BUILDING PERMIT
APPTICATION
Development Servlces
Bulldlng Dlvislon
l21 5th Ave N / Edmonds, WA t8020
425.771.0220
For handouts, submittal requirements, perrnít status and inspection
scheduling information go to; !vw!y.e.d.rngndlly,a€gv'
PLEASE NOTE: lntake appoirrtments are required for New Singb Family
Residences, targe Additions, ADU's, Âlew Commercial, and Maior'lenant
lmprovement application submittals, lf plans are prepared by a profession-
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electronic files on a flash drive or coordinate for electronic transfer.
Please coll 425-777-022A þ schedule an tntake appolntrnentl
I {Permit #:
"lftr r'rl! tr-ì.tl\
n AdditíonD AccessoryStructure/
Detached Garage
E Mechanicaltr Demolition
ngX¡tumbi
ü Remodel
ü New Síngle Famity/ Dupfex
D Fire Sprinkler
fl Re-RoofE New Commercial/ Mixed Use
U ]ANKE Signs
E Tenant lmprovement tl Other
Remodel Permlt tces ore bEsed on:
The volue of the work performed. lndicote the volue (rounded fo
lhe neorest dollorl of oll equipment, moteriols, lqbor, overheod,
ond the profit for lhe work indicqted on lhis opplicotion.
Voluolion:
Finished ü Unfinished DBasement sq ft:
lst Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
Date
I certify that the information I have provided on thls form/ãpplication is true,
correct and complete, ãnd that f am the property owñer or dulY author¡zed
agent of the property owner to strbmit a permit application tt the citY of
Edmonds.
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Print Neme:
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TYPE OF PERMIT (Provide Detoils on Poge 2)
PROPOSED NËW SQUARÊ FOOTAGE FOR THIS APPLICATION
PROJECT DESCRIPTION
JOB SITE INFORMATION/IOCATION: (Where the work ls taklng placef
Job Site Address:fi qn Ril,(,<T-
Parcel 00Lt3zo7lo looo
Lot /Unit/Suite #:
-
Subdivision:
PROPERTY OWNER:
Name:53a k"cc sT iLL
Mailing Address:'',þ wW sr
City/State/Zip:
Phone #:
a/
Email:
OWNER INSTALLATION: *lf yes, read and sign*
Will work be performed by the property owner? t ves if No
I own, reside in, or will reside in the completed structure. This
installation is being made on property that I own which is not
intended for sale, lease, rent, or exchange according to RCW
L8.27.094.
Owner Signature
APPUCANT / CONTACT INFORMATION:
Name of Applicant:Ita4 *t- y\Af,cFk\$t)LC/+ L
Mailing Address:6.t,
city/state/Zip' SÇ/¡tftlc NA 7Û1ffi
Phone #:7aû "7çn
E-mail:
GENERAL CONTRACÍOR: (lf different from
General Contractor:
Mailing ,Address:
City/State/Zip:
Phone #:
E-mail:
n*ru
ctw oF EDMoNrrs BUstNEss ucENsE * '¡ll?.- oz6tl24
WA STATE CONTRACTOR [ & I *: (CCBI A
Lrh ú TION DATE:
14y5,
Occupancy 6roup(s!:Occupant Load(s)
Type(s) of Construction Fire Sprinklers: Yes E No D
WA STATE ENERGY CODE: tf your project affects the buílding envelope,
mechanical systems, andlor lighting you must complete the
appropr¡ate WSEC forms.
DEFERRED SUBMITTF"LS: All commercial building perm¡ts that will require
assoc¡ated plumbing mechanical, flre sprinkler, and/or fire alarm
permits ãre applied for separately.
Tl / CHANGE OF USE / NEW BLDG: tnclude TRAFFTC tMpACT worksheet
BTUS Gas/ Elec/Other Aty
A/C Unit /Compressor
Air Hanclier /VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provldeeleva-
tions if a Commercial Bldg)
0ther:
q.tJ atv
Clothes Washer I
| -\
Tub/ Showers /-
Dishwasher Backflow Device (RPBA, DCDA, AVB)
Drinking Founta¡n Pressure Reduction/ Regulator Valve
Floor DrainlSink Refrigerator Water Supply
Hose Bibs Water Heater - Tankless? Y
Hydronic Heat Water Service Line
Sinks 4 X Other:
Toilets /1L Other:
GENERAL COMMERCIAL DATA
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
PLUMBING FIXTURE COUNTS (New, Relocated or re-piped)
BTUs qry BTUs Qty
A/C Unit Outdoor BBQ / Fire pit
Boiler Stove/Rangel0ven
Dryer Water Heater
Fireplace/ lnsert Other:
Furnace Other:
Qtv QW
Carbon Dioxide Nitrous Ox¡de
Helium Oxygen
tvtÉu¡Ldt Alt Other;
Medical - Surgical Vacuum
Type of structure to be demolished:
Other:
Square footage of structure to be demolished:
AHERA Surveydone? Y/N PSCAA Case #:
Critical Areas Determination:
Study Required E Conditional Waiver û Waiver E
Fill in Place E Fill Material:
Removal E Size of Tank (Gallons) _
Critical Areas Determination :
Study Required El Conditional Waiver E Waiver El
Grading: Cut _ cubic yards
cubic yardsFiil
Cut / Fill in Crltlcal Area: Yes E No El
APPLICATIONSI Applications are valid for a maximum of 1 year
ESLHA Applications, 2 years.
LICENSING: All contractors and subcontractors âre required to be licensed
wlth Washington State Depårtment of Labor & lndustr¡es and have a
current City of Edmonds BuEiness License,
GAS/FUEL CONNECTION COUNTS (New. Relocated or re-piped)
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or re-piped)
DEMOLITION
TANK
GRADE/FtLL/EXCAVATE
GENERAL PROVISIONs