20160812143748.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 f Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street =v Stjate. Zi Parcel #:
Subdivision/Lot #: Project Valuation: $ 2_C)c;C�
CA" PTV -
APPLICANT: Phone: Fax:
C�z� Cu.s e� 3� zit--76�13
A11 d11 d11 ress (11 S11 tree , City, State, p): E-Mail Address:
P1I( IER'1" � OWNER: P ne: Fax:
Addr��, (;Stp'cLh, City, State, Zip): E-Mail Address:
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 Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK:
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement:...m „ s . ft. Select Basement T e: Finished Unfinished _
lst Floor: ._ - ft. Gara e/Car ort:.e. — � .....-....rs . ft.
2"' Floor: �.sq. ft. Deck/Cvrd Porch/Patio:s
Bedrooms # Full-3/4 Bath #a „w Half -Bath # Other: , s . ft.
Fire S rinklers: Yes No Retainin Wall: Yes No
Grading: Cut cu. yds. Fill w _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.
M
Print Name: _. _� Owner ❑ Agent/Other ❑ (specify):
l2 r
'VgntlttAre� .�...-.-..� � •�" ,.__—.a_...._...... Date: . .. _,-.
FORM A L:\Building New Folder 2010\DONE & x-ferred to L-Building-New driveTorm A2014.docx Updated: 1/17/2014