20160920121245.pdfC` -P DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5"' Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
tll,I"`.1" A1�IIIII�SS (Street, Suite �� .
l�a w "� #, City 'State, Zi ,
Parcel #:
Subdivision/Lot #:
Project Valuation: $ /Kow
APPLICANT" 1
Phone.
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Fax:
Address 'S'twcc�i�y State ip,):
k�
E -Mail Address:
P100F.R" "N' OWNER: n
Fax:
'wdclrc�sS treet, Cit State, Zi
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E -Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:*
Pe:'
Fax:
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,�cl ress S'tt�et„ (Ity, State �i � �
E -Mail Address- r'
lM License tillwxp. Mf e:
�tt�i� " *�
*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 I City Business License #/Exp.dDay
9
DETAIL THE SCOPE OF WORK:
PROPOSED NEW S UARE FOOTAGE FOR THIS PROJECT:
Basement m _ _ • ft. Select Basement I" pe: Finished Unfinished '_J
Ist Floor: ... _._..._ .._ __ , _sr ft. (tiara ge/f.a ort:
Floor; s' , ft. Deck/Cvrd Porch/Patio:
Bedrooms # Full -3/4 Bath # Half -Bath # Other:
Fire Sprinklers: Yes LJ No Retaining Wall: Yes"1 No
Cit°4rditig: Cut_cu, yds. Fill, _,,,.ydCut/Fill in Critical Area: Yes www „ No �0_
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:" �I. rte' Owner AgertllC)t6roer LJ.(specify): ..
Signature: Date:
FORM A LABuilding New Folder 201MONE & x-ferred to L -Building -New driveTorm A2014.docx Updated: 1/17/2014