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City of Edmonds
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
Subdivision/Lot #:
Project Valuation: $
APPLICANT:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
PROPERTY OW ER:
Phone: Fax:
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/sPS- 77/- S.2o
Address (Str et, City, Ste, Zip):
E-Mail Address: �i J
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LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address;
CONTRACTOR:*
ne: Fax:
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-b LfE-Mail
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Address (Street, City, State, Zip): I
Address:
Wfate License #/E xp. Date,
A
*Contractor must have a valid City of Edmonds business license
prior to C i, LL " I ';. L
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #lEsp. Date:
a
DETAIL THE SCOPE OF WORK. .....
o
PROPOSED NEWSQUARE FOOTAGE
FOR THIS PROJECT:
Basement: s . ft.
Select Basement Ty e: Finished LJ Unfinished
1" Floor: s . ft.
Gara e/Car ort: s . ft.
27 Floor: s . ft.
Deck/Cvrd Porch/Patio: s . ft.
Bedrooms #_ Full-3/4 Bath # Half -Bath #
Other: -sq. ft.
Fire Sprinklers: Yes No LJ
I Retainin Wall: Yes No
Grading: Cut ._.._cu. yds. Fill cu. ds.
I Cut/Fill in Critical Area: Yes
No
71
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: _ ° r t'' �.
Owner 0 Agent/Other ❑ (specify):................
Signatures _ mm
Date:...-. ._ 16...'.....L..
FORM A LABuilding New Folder 2010\130NE & x-ferred to L-Building-New drive\Form A2014.doex Updated: 1/17/2014