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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 #: w 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: If 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 LJ 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