20161025143914.pdf-i '' 11777 "., '0',
DEVELOPMENT SERVICES
COMMERCIAL & MULTI -FAMILY BUILDING
PERMIT APPLICATION
ut 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 f Fax 425.771.0221
PLEASE REFER TO THE COMMERCIAL & MULTI -FAMILY BUILDING CHECKLIST FOR SUBMITTAL REQ UIREMENTS
PROJEC I' ADDRESS (Street, Suite*,, City St te, hilt)«
Parcel #:
.�74 2
Subdivision/Lot #:
Project Valuation: $ O(y�
wlJ
APPLICANT:
Phan �: Fax:
20� , oij
r ti ress (Street, City, $tat °„ Zip),
-'Call Addre, s:
PROPERTY OWNER:,
17k � �l I t� ,
Phone:
Fax:
-da_k
Address (Street, City, Sulte' .- i ); �
E-Mail Address:
I:M IS11! 5 AGENCY:
Phone:
Fax:
s (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*/tJ�l �(
Phone: Fax:
Address (Street,, City, State, zip),,
E-Mail Address
7_74
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 Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK:
_...�''..
_w. ......... ...........
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
1 st`Floor: --sq. ft. 2 na Floor: _
" s . ft, P Floor: ' s . ft.
Basement:'' s . ft. Gara e:
s . ft. , Deck/Cvrd Porch: sq. ft.
Other: s . ft. Retaining Wall: Yes
No Fire S rinklers: Yes No
Occu anc Grou s): Occu ant Load s):
T ` e(s of Construction:,
Gradin : Cut cu. ds. Fill cu. ds. I 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: ) e)e_ Owner ❑ Agent/Other (specify):
Sittat Date:
FORM E L:\Building New Folder 201000NE & x-ferred to L Building New drive\Fonn E 2014.doex Updated: 1/17/2014
Equipment Type
Appliance/Equipment Information (new and relocated)
Total # h
Furnace
Gas # _Elec
#_Othev
# BTUs: <100k_>100k_ Locations)
Air Handler / VAV
(circle selected)
Gas #
Elec # (')the l
# 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 #
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:
BTUs:
Icttttala(s,}:
Fireplace/Insert
BTUs:
Location(s):. ,_,
Stove/Range/Oven
Dryer
Outdoor BBQ
TOTAL OUTLETS
Fixture Typ7(new relocated)
Total # Fixture Type (new and relocated)
Total#
Water Closet (Toile`
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, neoA, 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 E LABuilding New Folder 2010\130NE & x-ferred to L Building-Newdrive\Form E 2014.docx Updated: 1/17/2014