20160506155453.pdfa % / DEVELOPMENT SERVICES
�d9 RESIDENTIAL BUILDING PERMIT
APPLICATION
s 1 121 5"' Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 Q Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
Subdivision/Lot #: i 1 / , Project Valuation: $ 1
APPLICANT: _ �l/ Phone. Fax:
F__ Iry A- I wl o /V 0 val
Address (Street, City, State, Zip): E -Mail Address:
PROPERTY OWNER:
JfVWPhone: Fax;
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Address (Street, City, State, Zip): E -Mail Address:
TD G AGENCY: Phone: Fax:
A ss (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* Phone: r Fax:
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Address (Street, City, State, Zip): E -Mail Address:
WA State License #/Exp. Date:
*Contractor must 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:
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: ... „___ sq. ft. Select Basement Type: Finished Lj Unfinished
1" Floor: _._ . ft. Gara e/C ort: ^s , ft.
2"' Floor: sq. ft. Deck/Cvrd Porch/Patio: sq. ft.
Bedrooms # Full -3/4 Bath # Half -Bath # Other: -sq. ft.
Fire S inklers: Yes Li NoI Retaining Wall: Yes LJ No
Grading: Cut cu. yds. Fill cu.yds. I 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: A/D Agent/other ❑ (specify):
Signature:"'..e��... Date:
-11
FORM A LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014
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