20160331132844.pdfDEVELOPMENT SERVICES
"M INRESIDENTIAL BUILDING PERMIT
APPLICATION
l �1 121 5`b Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 4 Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, ;dip): Parcel #:
p 4
Subdivision/Lot #: Project Valuation: $ 000
P'L1CAT: Phone: Fax.
Address (Stre
et, City, State, Zile): E-Mail Address:
3 9' � � "
P PERTY OWNER: Phone: Fax:
Address (Street, City, State Zip): E-Mail Address:
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* one: Fax:
StwV41 OLD r -0005'II
Address (Street, City, State, Zi )): E-Mail Address:
VIA
Llkc,
WA State License #/Exp. Date:
*Contractor roust have a valid City of Edmonds business license prior to
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK:
c�
PROPOSED NEW SQUARE F O "AGE FOR THIS PROJECT:
Basement: .__s . ft. Select Basement T12e, Finished Unfinished
1" Floor: s . ft. Gara e/C ort: _ _., _ 5 . ft.
rid Floor: s . ft. Deck/Cvrd Porch/Patio:
Bedrooms # Full-3/4 Bath # Half -Bath # Other: sq. ft.
Fire S r nklers: Yes r7 No Retainin Wall: Yes No
Grading: Cut cu. yds. Fill cu.yds. Cut/Fill in Critical Area: Yes LJ No
I declare under penalty of perjury laws 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. @
f ttFrt
Print Name: r5e,S 1 "r, l , "+ Owner ❑ Agent/Other ❑ (specify):. t
Signature: ' Date:
FORM A LABuilding New Folder 201000NE & x-ferred to L-Building-New drive\Form A2014.doex Updated: 1/17/2014
?° k—