20160520103832.pdfDEVELOPMENT SERVICES
b` RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5`h 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
II;a
'' ADDRESS (Street, Suite #, City State„ lily): Parcel #:
ILL, t y—
Subdivision/Lot #: Project Valuation: $
APPLICANT: Phone: Fax:
4-4-
0—
Address (Stet, City, State, 7 � � � E -Mail Address:
Z ti
PROPERI 1C)WNER. Phone; Fax.
r J'
A thcsr (Street, Cil „ State, Zip): E -Mail Address:
.I t J.
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:*Phone: Fax:
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 Busies License ll/Exp, Datc;
DETAIL THE SCOPE OF WORK
PROPOSE_ D NEW S2UARE FOOTAGE FOR THIS PROJECT:
Basement: _________sq. ft. Select Basement Type: Finished � Unfinished
1 S` Floor: s . ft. Gara e/Car ort:
2" Floor: �s . ft. Deck/Cvrd Porch/Patio:
Bedrooms # Full -3/4 Bath # Half -Bath # Other: .... -. ...W_... -s" . ft.
Fire Sprinklers: Yes No 17 Retaining Wall: Yes 17 NoEl
Grading: Cut cu. yds. Fill cu.yds. Cut/Fill in Critical Area: Yes LJ No LJ
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. p p p
Print Name: f `^� `'`_ _ .......... Owner 0Agent/Other [K (specify)': -.,cam....::.
Signature: ..._...., ...._ �..,. Date:
FORM A L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form A2014.doex Updated: 1/17/2014