20160802122450.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
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
PRO ,JECf°l AI')I 1 ,SIS Slrce , Suite #, City State, Zip): Parcel #:
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Subdivision/Lot #. Project Valuation: $ �� a Cx!)
AIS " 1"vV4I��� Phone: Fax:
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Address (Street, City, St Z' E�-1�I it Address:
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PROPERT O NER: Ph ne: Fax;
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Address Street, City,State, i E ail At dress: r
LENDING AGENCY Phone: Fax„
Address (Street, City, State, Zip): E-Mail Address:
CONTRACT R:* Ph 1 =Fa(
Address (Street, City, State, Zip): E-Mil 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:
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DETAIL °l Il lw S'(0' l"P, OF WORK:
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PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: s . ft. Select Basement T e: Finished Unfinished
ls`Floor: s . ft. Gara e/Car ort:
2" Floor: _ _mmmmmm,,,, ,sq. ft. Deck/Cvrd Porch/Patio: -,,
Bedrooms # Full-3/4 Bath
..� #W_.._ .. Half -Bath #�. � - Other ......e�.,.m ._�... �.......-s . ft.
Fire S rinklers: Yes No Retamm Wall: Yeso No
Grading: Cut cu. yds. Fill cu.yds. Cut/Fill in Critical Area: Yes LJ 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.
Print Name: J,,,,�, _.. Owner ❑ Agent/Other ❑ (specify):,.,.,.
Signature: '�_�.� ........ Date ...:.
FORM A L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Forrn A2014.docx Updated: 1/17/2014