20160916142627.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
10 APPLICATION
st I, �1s� 121 5`4 Avenue N, Edmonds, WA 98020
City Edmonds Phone 425.771.0220 Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State Zip):
6ibr►� o0%
Parcel #:
a a �k , s
o
Subdivision/Lot #:
Project Valuation: $ o v
APPLICANT: S o w4 a .' -
Phone: Fax,
Address (Street, City, Stals:„ ✓ip),
E -Mail Address.
PROPERTY OWNER:
Phone: Fax:
�% oYl
c���' - �
Address (Street, City, State, Zip): D Inti u�v S
E -Mail Address:
-� *u s�_ R ma m
LEND17AGENCY:
Phone: Fax:
Ac: Ss (Street, City, State, Zip):
E -Mail Address:.
CONTRACTOR:* .56 0 -�-'A tJ Lcs T PLLcvvA F3/A/(,r
Phone- q Fax:
2 -1 2774
Address (Street, City ,,Sta mp): S„ea
5
E -Mail Address„
C., X i�t
�
*Contractor
WA State License #/Exp. Date:
P C
must have a valid City of Edmonds business license
prior to
(ATR W
City Business ' ease #Jlr p. Date„
doing work in the City. Contact the City Clerk's Office at 425.775.2525
Cl.•
DETAIL THE SCOPE OF WORK:
PROPOSED NEWSQUARE FOOTAGE FOR THIS PROJECT:
Basement: sq. ft.
Select Basement T e: Finished LJ Unfinished
1" Floor: _S2. ft.
Garage/Carport: S2. ft.
2"d Floor: sq. ft.
Deck/Cvrd Porch/Patio: -,sq. ft.
Bedrooms# Full -3/4 Bath # Half -Bath #
Other: s . ft.
Fire S rinklers: Yes No M I
Retaining Wall: Yes No
Cira ing: Cut etl, yds, ball cut yds, ICut/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: S f: _
Owner ❑ Agent/Other (specify): _
Signature:._. __..........:...................... ._.�._
Date:�_.�G
iv
FORM A LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014
OV' E QAj rrl
40
City of Edmonds
Equipment Type
Furnace
Air Handler / VAV
(circle selected)
Gas #_Elec
Gas #_T
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION FORM A
1215 Avenue N, Edmonds, WA 98020
Phone 425.771.0220 JI Fax 425.771.0221
ow
MECHANICAL
Appliance/Equipment Information (new and relocated) Total #
#_Other:........ # BTUs: <100k >100k_ Location(s)
Elec #Other:# CFM: <lOk_ >lOk Location(s)�ITIT�,
AC / Compressor /
Boiler / Heat Pump /
Gas # _Elec
#—Other:_...............
_ W,_ # BTUs: <100k,......................... .... _100k-500k, 500k-1Mil
Roof Top Unit
HP:
<3, 3-15, ________15-30
Location(s) �ITmIT
(circle selected)
Hydronic Heating Gas #_Elec
#_In-Floor
_Wall Radiant, Boiler BTUs:, Location,ITITITIT_ .. ----
Exhaust Fans (single Bath #_Kitchen
#_Laundry #
duct)
_ _t;)tlaerz ........_ ................................................
Fireplace Gas #_—Elec
# aC)thelw
# Location(s)
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs: .-
Location(s)s_IT
Furnace
_
BTUs: .............. --___
Location(s):____
Water Heater
BTUs:
....... Location(s):_, ................ v
Boiler
BTUs:.__
Location(s). ______µµµµwww
Other: ._..
BTUs: „w_
Location(s):..........
Fireplace/Insert
BTUs:
_ Location(s):
Stove/Range/Oven
Dryer
_ ................... ...........
Outdoor BBQ
--------------
TOTAL OUTLETS
Pl,tJMBIN(;
Fixture Type (new and relocated)
FIXTURE COUNT
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
❑ No ❑
Hydronic Heat in: Floor 0 Wall ❑
Floor Drain/Floor Sink
Other:
......_
Refrigerator water supply (for water/ice dispenser)
... ......__........__. ...... ._......
Other:
FORM A LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form A2014.doex Updated: 1/17/2014