20160516095637.pdfa DEVELOPMENT 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
PiI DJECT I)DRE'SS Street, 11he #, City State, Li ):
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Parcel #: ,
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Subdivision/Lot #:
Project Valuation: $
APPLICANT: —
Phone: Fax:
Address (Street, Ci , State, Zip):
E-Mal Address: c�
PROPERTYf)'4".Nl�l "� „
Phone:
Fax:
Ad ss („ reet, Oily, State, Zip):
1,1�i It
E-Mail Address:
ENDIN AGENCY:
Phone:
Fax:
A Is (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
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Phone: Fax:
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AddressSt� eet, Cit�, Sty te, 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: "C _� � ` �—
PROPOSED NEW S+ UARE FOOTAGE FOR THIS PROJECT:
Basement: _...... w_ 's ft. Select Basement Type. Finished Lj Unfinished
151 Floor:___Ss. ft. Gara e/C ort: -sq. ft.
7 Floor: -_ _ ......, s . ft. Deck/Cvrd Porch/Patio: sc . ft.
Bedrooms # Full-3/4 Bath # Half -Bath # Other: _s . ft.
Fire S rinklers: Yes No= Retaining Wall: Yes LJ No
Grading: Cut cu. yds. Fill _ cu.yds. Cut/Fill in Critical Area: Yes NoLJ
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 f t T Owner ❑ Agent/OtherEl (specify):
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Si,gna9ar Date: r c>
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FORM A LABuilding New Folder 2010\130NE & x-ferred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014