20160502152113.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5b Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 It Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
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PRO%T ADD" (St eet, Suitt #, City State, Zip): �J&
Subdivision/Lot
APPLICA�E_
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Address (Stre ,Slat
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PROPEWfY.OWN : (qs"kf EAq
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Address (Street, ;iState,?�ip):
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LENDING AGENCY:
Address (Street City, State, Zap):- �,e -,; (I,( -
CONTRACT(T*
Address (Street, City, State, Zip):
Parcel #:
Project Valuation: $
VP1130ne, Fax:
E -Mail Address:
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Phone: I Fax:
E -Mail Address:
Phone: Fax:
E -Mail Address:
Phone: Fax:
E -Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to J�
doing work in the City. Contact the City Clerk's Office at 425.775.2525 1 City Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK: . . ...... .... .. . .....
. . . .............
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............................ . . . . . . ...................... . . .....................
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: N AC -sq. ft.... Select Basement ly2e: Finished LJ Unfinished
1St Floor: ZI S2. ft. Gff2Le/C!Mort: sq.
2°d Floor: sq. ft. Deck/Cvrd Porch/Patio: S2. ft.
Bedrooms # Full -3/4 Bath # Half -Bath # Other: scl, ft.
Fire Sainklers: Yes LJ 7,40,17 Retaining Wall: Yes No7
Grading: Cut cu. vds. 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.
n
J, V Owner Agent/Other 0 (specify).
Print Name., td C- FA I -
Date:
FORM A LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Fom A2014.doex Updated: 1/17/2014