20160511101828.pdfDEVELOPMENT SERVICES
' RESIDENTIAL BUILDING PERMIT
APPLICATION
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
PROJE T ADDRESS (Street,Suite # City State,
Parcel #:
Zi
06
Subdivision/Lot #:
Project Valuation: $
APPLICANT:�� Cif l� '""'m;t "A C o 1
PlteV� Fax:
Address (Street, City 1
E-Mail ress:
PROPERTY OWNER:
Phone. Fax:
Address (Street, City, State, Zip):
E-Mail Address:
1, E N �DIN C!,ACEN+CY`:
Phone. Fax:
ss (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
r
WA State License /Ex Date: ,., w .., AA*Contractor
<
must have a valid City of Edmonds business license prior to �� t d a.
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 Unfinished 17
1" Floor: a . ft.
Gara e/C ort: s . ft.
2° Floor. _ _ s . ft.
Deck/Cvrd Porch/Patio: s . ft.
Bedrooms # Full-3/4 Bath # Half -Bath #
Other: s . ft.
Fire S rinklers: :Yes= No
Retaining Wall: Yes r7 No
Grading: Cut cu. yds. Fill cu.yds. 1, Cut/Fill in Critical Area: Yes LJ NoEJ
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.
�a �_ / Owner ' �� ❑ AgenbOther�'(specify):
Print Name: �"""'" wt� �^
Signature:�� �.. Date:
FORM A LABuilding New Folder 2010\DONE & x-ferred to LrBuilding-New drive\Form A2014.doex Updated: 1/17/2014