20160923085252.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
yAPPLICATION
St 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 Q Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
I 11 'EWICTADDRESS (Street Suite It Cit State, zip):' ' Parcel #:
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Subdivision/Lot #: Project Valuation: $
APPLICANT: Phone: Fax:
Sea-, I-- -_ -� ydsI /-
Address
(Street, City, State, Zi�: 02-0 E -Mail Address:
3-5 ..
PROPERTY OWNER: r �^ Phone:
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Address (Street, City, State, Zip: p pp E -Mail Address:
LENDING AGENCY: f Phone: Fax:
Address (Street, City, State, Zip). E -Mail Address..
CONTRACTOR:* I_ Phone:
Address (Street, City, State, lilt): O E -Mail Address:
Z ; � � Rv"
7 Ave . �e�" Inl�
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�Btas��sLicense #/Exp. Date
2
DETAIL THE SCOPE OF WORK .,.,. J ` �^�.0. u- •
PROPOSED NEWS LIARE FOOTAGE FOR THIS PROJECT:
Basement: .-,_. _ ..._.. w...w SC, ft. Select Basement "r . e: Finished Unfinished
..
ISiFloor:......
2""' Floor: st. , ft. Deck/Cvrd Porch/Patio: _a ., , � �c . ft.
Bedrooms # Full -3/4 Bath # Half -Bath # Other: _ - s ft.
Fire Seo nklers: Yes _N77 Retainin E Wall: Yes No
Grading: Cut ___cu. .,cu. yds.. Fill _µwww _m„ _cu.yds. Cut/Fill in Critical Area: Yes No
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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 Agent/Other ❑ (specify):.„.Mm
_ � //-,70d
Signature: —_.. ��� Date:�..... m,� ,....
FORM A L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014