20161007121120.pdf. ED
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 50' Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 It Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
�7U L e- ? L
Subdivision/Lot #:
Project Valuation: $
APPLICANT:
Phone:
Fax:
9 TF N,\i
yv; 7'9;d -7 "i3%
Address (Street, City, State, Zip):
E-Mail Address:
PROPERTY OWNER:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
1 �/iO 5S5' ?L 1-s
tENDI AGENCY:
Phone: Fax:
A' tiff (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
WA State l.i enw, #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to
A A ! -y' l i
doing work in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
Y
DETAIL THE SCOPE OF
WORK.'
.t
PROPOSED NEWSQUARE FOOTAGE
FOR THIS PROJECT:
Basement: ._ SS. ft.
e: Finished Unfinished
Select Basement T ,
1" Floor: s . ft.
I Gara e/Car ort: SS. ft.
27 Floor: s . ft.
Deck/Cvrd Porch/Patio: s . ft.
Bedrooms # Full-3/4 Bath # Half -Bath #_
I Other: s . ft.
Fire Sprinklers: Yes
0 No
Retaining Wall: Yes
U No
Grading: Cut cu. yds. Fill cu. ds.
I Cut/Fill in Critical Area: Yes I 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.
f �_
Print Name: �C��'� ` " �i�
Owner ZA ❑
Signature:
ent/Other(specify):
g r
Date: Q 7 t b
-
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
APPLICATION FORM A
"sr 1
121 5`s Avenue N, Edmonds, WA 98020
City of Edmonds
Phone 425.771.0220 1& Fax 425.771.0221
Equipment Type
Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas #
,Elec #, .....1)ther:
#_ m BTUs: <100k__..0 >100k ,_ Location(s).,,,,,
Air Handler / VAV
(circle selected)
Gas # .......-Elec
#Other:
_ # CFM: <10k_ >10k Location(s)
AC / Compressor /
Boiler / Heat Pump /
Gas #--_,_Elec
# Other;,-_
# BTUs: <100k, 100k-500k, 500k-1Mil
Roof Top Unit
HP:
<3, 3-15,
15-30 Location(s) ..........
(circle selected)
.............________
Hydronic Heating
Gas #_Elec
#_In -Floor
_Wall Radiant_ Boiler BTUs: ._ Location
Exhaust Fans (single
duct) Bath #_Kitchen
#_Laundry # t'1th1,°:. _#..._...__
Gas #_Elec
#_Other:_
# Location(s)._,.._-_ �mmITITITIT,,
JFireplace
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
AC Unit
BTUs:
........ Location(s): _ ......... _--
7tal
Furnace
BTUs:
Location(s):,
Water Heater
BTUs:
Location(s). ......,
Boiler
BTUs:
_ Location(s): _ _..
Other:
BTUs:
Location(s):
Fireplace/Insert
BTUs:
I'mation(5'):
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 2010\130NE & x-ferred to L Building -New drive\Form A2014.doex Updated: 1/17/2014