20160407133726.pdf-
DEVELOPMENT DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
c; 1 121 5`h 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
P1t O,IECT ADDRESS (Street, Suite #, City Stag Zip). , Parcel #:
M" 1 � 4 n w �"DD i
'� N
Subdivision/Lot #: Project Valuation: $
i
APPLICANT: Phone
: Pax:
i} ®tUL
City, p
(Street, , State, Zip): E-Mail Address:
Address (Sty �"'�,� ).
PROPE OWNER: Phone: Fax:
C(_ 1 9 L1,
Address (Street, Cit State, Zip). E-Mail Address:
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
Phone: Fax:
CONTRACTOR: � � � ® lei � � & 9�-26
Address
(,Str
eet, CA State,, Zip): E-Mail Address:
L40D 1AV'N.
WA State License #/Exp Date:
*Contractor must have a valid City of Edmonds business license prior to AC l;'
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:��
..,
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: s . ft. Select Basement T e: Finished LJ Unfinished
lst Floor: sc . ft. Gara
_ _s ft.
2°Floor: Deck/Cvrd Porch/Patio: s. ft.
Bedrooms # Full-3/4 Bath # Half -Bath # Other: s' • ft.
Fire S rinklers: Yes D No Retaining 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.
Print Name: ""� "� '�� ��' t" Owner ❑ Agent/Other [2 (specify): . t.r - r& "" v""'
.
Signature: Date: ffi
FORM A LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014