20161003123301.pdfa Ia DEVELOPMENT SERVICES
i RESIDENTIAL BUILDING PERMIT
APPLICATION
fat 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST
FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (St eet, Suite City State, Zip):
Parcel #:
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Subdivision/Lot #:
Project Valuation: $ , ou
APPLICANT:
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Phone: Fax;
_+z5)T_3 1- 31151S
Address (Street, City, State, Zip):
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E-Mail Address:
PROPERTY OWNER:
Phone: (20 Gsl i - 2331 Fax:
Address (Street, Ci , St to Zip):
E-Mail Address:
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LENDING AGENCY:
Phone: Fax:
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Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* �
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Address (Street, City, State, Zip):
E- ail Address:
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WA State license #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to W I
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: t w 1
PROPOSED NEWS UARE FOOTAGE FOR THIS PROJECT:
Basement: s . ft.
Select Basement T e: Finished LJ Unfinished
1" Floor: _ ft.
Gara e/Car ort: �... .�s . ft.
2°d Floor: _ ft.
Deck/Cvrd Porch/Patio: __ ....._S .. ft.
Bedrooms # Full-3/4 Bath # Half -Bath #
Other: . _ -,sq. ft.
Fire Sprinklers: Yes LJ No LJ
Retaining Wall: Yes NoLJ
Grading: Cut cu. yds. Fill cu.yds.
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.
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Owner ❑ Agent/Other (specify):
Print Name: w_ _.�
,
Signature:.,
Date:
FORM A LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014
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DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
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APPLICATION FORM A
121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds
Phone 425.771.0220 A Fax 425.771.0221
Equipment Type
Appliance/Equipment Information (new and relocated) Total #
Furnace Gas #—Elec
#__—Other:
# BTUs: <100k_ >100k_ Location(s) _ . ,
Air Handler / VAV Gas #_Elec
(circle selected)
#—Other, a ......,,,_
# CFM: <lOk_ >lOk_ Location(s)
O......
AC / Compressor /
Boiler / Heat Pump / Gas #m .—Elec
#..,,Other:
# BTUs: <100k, _______,___100k-500k, 500k-lMil
Roof Top Unit HP:
<3, 3-15,
15-30 Location(s)
O'
(circle selected)
''
Hydronic Heating Gas #_Elec
#_In -Floor
_Wall Radiant_ Boiler BTUs: Location
Exhaust Fans (single Bath #_Kitchen
duct)
#_Laundry #. Outer:
Fireplace Gas #_Elec
#_Other:
# Location(s).__.___
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated) Total #
AC Unit
BTUs: _ _
Location(s):__.._...___
Furnace
BTUs: ...._........
__ Location(s):
Water Heater
BTUs:
Location(s):,... . . ..........
Boiler
BTUs: _
Location(s):
Other: w .........
BTUs: �....._._
Location(s):_. . ......... ........
Fireplace/Insert
BTUs:
_ITITIT l ocation(,$):,,IT . IT-
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
Fixture Type (new and relocated)
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 ❑ Wall
Floor Drain/Floor Sink
Other:
------ ...............
Refrigerator water supply (for water/ice dispenser)
Other:
FORM A LABuilding New Folder 201000NE & x-ferred to L-Building-New driveTorm A2014.docx Updated: 1/17/2014