20160729121303.pdf11 hD �I
Al
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
p APPLICATION
t� 121 5"' Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 9 Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip'): Parcel #:
w 7 N ru 0 '" r `.
Subdivision/lAM #:
Project Valuation: $
Al 9100
Al'L ICAN"I":
Phone:Fax:
" 7 7 � "� °) 7•
Atldiss (Street, City, Stilt „ Zip): 1:-allaii Address:
v 16 . V4 2t4 e'
PROt"ERTY OWNER: Phone: Fax:
Address (Street CityState Zip): E-Mail Address:
,
I ENbINt, AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
C''O1I"1 rt4 1'4)It:* Phone: Fax;
✓I C
Zss O„c" Zip), E-Mail Address:
Address (Street, (:'ityS« ttcif v ✓ f✓ls 2 sue'
2C_V6 WA State License #/Exp, Date:
*Contractor must have a valid City of Edmonds business license prior to I : +a 12 w
doing work in the City. Contact the City Clerk's Office at 425.775.2525 � City flu iness� �J case #/Exp. Date:
DETAIL THE SCOPE OF WORK: ,. ......
PROPOSED NEW
Basement: _.. ���....--._ ...-- ...mm__.___s °, ft.
lst Floor:-.w�.�.�_.. ....... ,9t�, ft.
2°"Floor:
Bedrooms #_ n, Full-3/4 Bath # w, Half -Bath #,
Fire S orinklers: Yes LiNo
Cxfadinw: Cut �m ._. _._cu, yds. Fill
Z L a°) /e
FOOTAGE FOR THIS P"rfIOJEI'wT;
Select Basement Type: Finished LJ Unfinished
Gara,e/Car iort:.��... .. � ... � .._. sq: ft.
Deck/Cvrd Porch/Patio:
Other
.. tetalltin.�,.._—
Wall: Yes No
Cut/Fill in Critical Area: Yes _' No Ll
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: r , � �L Owner W Agent/Other ❑ (specify):
� I'll
Signature: �m.... w — .. ._. ..... Date:..�....
FORMA LABuilding New Folder 2010\DONE & x-fenced to L-Building-New drive\Form A2014.docx Updated: 1/17/2014