20160624155109.pdfAS
" DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
I,.ti 121 5'h Avenue N, Edmonds, WA 98020
st
City of Edmonds Phone 425.771.0220 ft Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite It', City State, Zip):
Parcel #-,
Subdivision/Lot #:
Project Valuation: $
3c,
AP LICANT:
Phone: Fax:
tgiE 1( -AAT—
—. 7-1 - 0942 -
Address (Street, City, State, Zip): (
E- .ail Adc� ess:
c g�a r
( 7 . yy a3 1V
i rt -11111111100-V4 ( t DC7
PROPERTY OWNER:
Phone: Fax:
�tll�v-ei
Address (Street, City, State, Zip):
E -Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
(`ON' IW'1TOR:*
A ,Nk-fb '"''-0oi (AJC
�P$hogne: ] Fax: ( g
12„S —7 _y—S�1 d 6
Address (Street, Gity, State, Zip): E -Mail Address: p
16 st`°� IS Lw•Weda 3`� �c���� va�,r.� tu�St-ak .0 ,ate
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to Awwxa 3
doing work in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
Al — z?C,3
DETAIL THE SCOPE OF WORK: _._�� ��' �'
.�_ —.
PROPOSED NEW S t)ARE FOOTAGE FOR THIS I)ROJEC"'l't
Basement:st ft.
Select Basement T e: Finished Ll Unfinished
1't Floor: �._....� .._..._. _.st . ft.
Gara e/Car ort: ... _ .. .. w. _.. ft.
2n' Floor: .. _ sq. ft.
Deck/Cvrd Porch/Patio:
Bedrooms # Full -3/4 Bath # Half -Bath #--.
Other:,,,..._ m_. sq. ft.
Fire S rinklers: Y;s7J No
Retaining Wall: Yes N771
Grading: Cut cu. yds. Fill —cu.yds.
Cut/Fill in Critical Area: Yes '. 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.
P(kzq7�
Owner �Agent/Other ❑ (specify),
Print Name: _ .._
rT
Date: 12N20 f 6
/
Signature: _ A..... __� ��._..__
-._... _..w ....�
ME
FORM A LABuilding New Folder 20 1000N & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014
FORM A 1-Muilding New Folder 2010\130NE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
P
APPLICATION FORM A
sy I
121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds
Phone 425.771.0220 2 Fax 425.771.0221
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas #, ...-.Elec
#.............Other: _......----------
BTUs: <100k....�-�_ >100k__w. Location(s)W.....ww..................... ......
Air Handler / VAV
Gas #,,,,---Elec
#
#_w <10k, >10k Location(s),
(circle selected)
�-~Other:µ-
„CFM: „,
AC / Compressor /
Boiler / Heat Pump /
Gas #.
Elec #_Other:
#_________ BTUs:_____ e___<100k- ___________ _100k-500k, __________500k-1Mi1
Roof Top Unit
HP:
<3, 3-15,
15-30 Location(s)
(circle selected)
m.........w_..............................................�.�.�.�.�.�.�.�.......�....
Hydronic Heating
Gas #
Elec # „In-Floor ......—Wall
Radiant-,,,— Boiler BTUs:—,—.— Location ,,. ,,,,,.w � _. ,, _,.
Exhaust Fans (single
Bath #
#_Laundry
# #,
duct)
_Kitchen
_Other: ........
Fireplace
Gas #J
Elec#Other:,wwwwww
µµµwww-_ ,,,,, # _ Location(s) yvr�e ecu__
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated) Total #
AC Unit
BTUs:
Location(s):_
Furnace
BTUs:µ
Location(s):,__
Water Heater
BTUs:.-._
Locations) .._.... _.....__..........._.._... �a_
Boiler
BTUs:
Location(s):. m _....,.�........�.�..w.........�.... .............
Others
BTUs:
Location(s):,-
__-Fireplace/Insert
BTUs: , 31 ��Ci
Location(s): Li fN f,
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
PLUMBING FIXTURE COUNT
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.)
Water Service Line
Tub/Shower
Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes
❑ NoF—]
Hydronic Heat in: Floor ❑ Wall E]
Floor Drain/Floor Sink
......
Other:
-_w_w_���-wwwwwwww_w� w
...........--..-�
_.......
.---_....._.............._...._-....-.._- .........
Refrigerator water supply (for water/ice dispenser)
Other:
FORM A 1-Muilding New Folder 2010\130NE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014