20160908122743.pdfw,M ej
a DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
N APPLICATION
121 5"' 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 ('
Subdivision/Lot #:
APPLICANT:
PROPERTY OWNER:
Address (Street, City, State, Zip):
LENDING AGENCY:
#, City state„ Zip)
Parcel #:
Project Valuation: $
Phone:
E-Mail Address:
Fax:
Phone: Fax:
E-Mail Address:
Phone: Fax:
Address (Sheet, City, State, Zip): E-Mail Address:
CONTRACTOR:* Phone: Fax:
,
Address (Street, City State, Zip): f - ail Aahhe ss
j. License 1171 xp WA State Lice .. � � o
.� Date:.
*Contractor must have a valid Cityo Edmonds biesmess lic •wse 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: -W_.. ......�.�...._.. _.. .... ,......_
PROPOSED NEWS DARE FOOTAGE FOR THIS PROJECT:
Basement: .. __.. .._ s . ft. Select Basement T e: Finished F7 Unfinished
ls` Floor: sa , ft. G ara;e/Ca tart; sc a ft.
2" Floor: ...__..m �..° .. st . ft. Deck/Cvrd Porch/Patio:
Bedrooms # Full-3/4 Bath # , m .° Half -Bath # _ Other: ° ,
Fire S 1°itlitiers: Yes No Retainin Wall: Yes 17No
�C,:ii-ttdin : Cut —cu. yds, Fill .. _m _ cu.yajs. Cut/Fill in Critical Area: Yes No
El
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:Owner 14 Agent/Other ❑ (specify):
�
�c ,e.
Signature: �""� Date `"" �. .... Z:..a-... .......... .-
FORM A L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014,docx Updated: 1/17/2014