20160527142125.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220:k Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROjECT r)D,RESS 'Street Suite #, Citytate, Zip): Parcel #:
Subdivision/Lot Project Valuation: $
APPLICANT-: Phone: Fax:
'"1V11L> ( . I
Address (Street, City, State, Zip): E -Mail Address,
PROPERTY OWNER Phone: Fax:
Waal 4( 0 YJ
Address (Street, City, State, Zip): E -Mail Address:
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* Phone:
6,//5-60
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:
"Je
41 v
DETAIL THE SCOPE OF WORK:
.......... . . .
........................... . . . .
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: . .............. sq. ft. Select Basement TX2e: Finished LJ Unfinished
1" Floor: sGarage/C2Mort: --sq. ft.
2 Id Floor: —sq. ft. Deck/Cvrd Porch/Patio: sq. ft.
Bedrooms # Full -3/4 Bath # Half -Bath # Other: sq.
Fire Sprinklers: Yes No LJ . .... Retaining Wall: Yes No
Grading: Cut cu. yds. Fill —cu.yds. I Cut/Fill in Critical Area: Yes J_J No E]
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.
XI uni
Print Name: q Owner _]E� Agent/OtherE] (specify):
Sig]!tom Date.
FORM A LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Fonn A2014.doex Updated: 1/17/2014
EXEMPTION FROM CONTRACTOR
REGISTRATION VERIFICATION
FORMI)
The undersigned property owner or authorized person as described below, has applied for a
building permit from the City of Edmonds and claims that he/she/it is exempt from providing
contractor registration in accordance with the provisions of RCW 18.27. The property owner or
authorized person, by their signature below, hereby verifies to the City of Edmonds that:
❑ Value of work under $500.00. The aggregate contract price of labor and materials and all
other items required for the project is less than $500.00 and is not part of a larger operation
to be undertaken on the property. This exemption does not apply to a person who advertises
or puts out any sign or card or other device which might indicate to the public that lie/she is
a contractor, or that he/she is qualified to engage in the business of contractor. RCW
18.27.090,(9).
❑ Owner who contracts for a project. A property owner contracting with registered
contractors for the project, and who him/herself is not performing any activity of a
contractor for the purpose of leasing or selling improved property that he/she has owned for
less than twelve months. RCW 18..27.090(11).
Work performed personally on own. property. Anyone personally working on property
lie/:she owns, or at which he/she resides, as long as the property owner, or resident, does not
perform any activity of a contractor on his/her property for the purpose of selling,
demolishing, or leasing the property. RCW 18.27.090(12).
❑ Use of own employees. Property. owner using him/herself or his/her own employees to
perform maintenance, repair, and. alteration work in or upon his/her own property. RCW
18.27.090(13).
❑ Licensed Architect, engineer, electrician or plumber. All work performed under this
permit will be performed by an architect, civil or professional engineer, certified electrician
or certified plumber operating within the scope of his/her certification. RCW 18.72.090(14).
❑ Other. Specify which provision of RCW 18.27.090 applies:
THE UNDERSIGNED PROPERTY OWNER OR AUTHORIZED PERSON HEREBY VERIFIES
THAT ALL INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE
BEST OF HIS OR HER KNOWLEDGE AND ACKNOWLEDGES THAT IF ANY OF THE
INFORMATION PROVIDED ON THIS FORM IS FALSE HE OR SHE UNDERSTANDS THAT THE
BUILDING PERMIT WILL BE IMMEDIATELY REVOKED AND ALL FEES PAID FORFEITED.
DATED this day oft' , 20 .
u
U
PROPERTY OWNER/AUTHORIZED WITNESS_
PERSON _ _..
S Bata/are
"—r4om q 5 �Jokv) r�
Print Name
Signature
Print Name
LATEMP\BUILDING\IiANDOUTS REVISED IN 2009\PREVIOUS HANDOUTS\FORMS\CONTRACTOR EXEMPTION FORM
D.DOCREVISED 7/07
City of Edmonds
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION FORM A
121 5`b Avenue N, Edmonds, WA 98020
Phone 425.771.0220!k Fax 425.771.0221
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace Gas #_Elec
#_Other:
# BTUs: <100k >100k_ Location(s)
Air Handler / VAV
Gas #_Elec
#_0ther:
# CFM: <10k_ >10k Location(s)
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Gas #__ ...._Elec
# thcr:
_ # BTUs: <100k, 100k -500k, 500k-1Mil
Roof Top Unit
HP;
<3, 3-15,
15-30 Location(s)
� (circle selected)
Hydronic Heating
Gas #_Elec
#_In -Floor
_Wall Radiant_ Boiler BTUs: Location--
ocationExhaust
ExhaustFans (single
Bath #_Kitchen
#_Laundry # #
duct)
_Other:
Fireplace
Gas #_Elec
# Other:
#_ Location(s) .................
Dryer Duct
FUEL GAS
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:
Location(s):
Furnace
BTUs:
Locztion(s):
Water Heater
BTUs:
Location(s):
Boiler
BTUs:
_ Location(s):
Other:
BTUs:
Location(s):
Fireplace/Insert
BTUs:
Location(s):
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
PLUMBING
Fixture Type (new and relocated)
Total # Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
I Water Service Line
Tub/Shower
Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes E] NEE-
Hydronic Heat in: Floor ❑ Wall ❑
Floor Drain/Floor Sink
Other:'
Refrigerator water supply (for water/ice dispenser)
Other:
FORM A L:\Building New Folder 2010\DONE & x-ferred to I-Auilding-New drive\Form A2014.docx Updated: 1/17/2014