20161027083834.pdfvp DEVELOPMENT SERVICES
1Y RESIDENTIAL BUILDING PERMIT
APPLICATION
k't ayy 121 5`h Avenue N, Edmonds, WA 98020
tl.
City of Edmonds Phone 425.771.0220 ft Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite, , City Stag, lily : �� my
Parcel #:
r � C
Subdivision/Lot :
Project Valuation: $
7y
APPLICANT-;, 1�
P e: � � r / Fax:
Add ss (Street, City, S/tC�ajte, Zip)::
Address:
�E+-Mail
PROPERTY OWNER:
Phone: Fax:
Address (Street„ C'ily, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* ^ le i n
Phone: Fa.
Address (Street, City, State Zip):
Laqa
E-Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to GPD aa6 2E �V56 ao l b
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License. li/ ""x . Date:
DETAIL THE SCOPE OF WORK: ®........
..-.,. _.. .... _ m....._......................................................�eee �e��eeeee eeeeee�....
PROPOSED NEW S UARE FOOTAGE FOR THIS PROJECT:
Basement: s . ft.
Select Basement T e: Finished LJ Unfinished
V Floor: s . ft.
Gara e/Car ort: s , ft.
2° Floor: s . ft.
Deck/Cvrd Porch/Patio: Sq. ft.
Bedrooms # Full-3/4 Bath # Half -Bath #
Other: -sq. ft.
Fire Sprinklers,:, Yes No
Retainin Wall: Yes NoLl
Grading: Cut cu. yds. Fill cu. ds.
Cut/Fill in Critical Area: Yes L 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
Print Name: ... Owner ❑ Agent/Other (specify);
Signature: Date; 19-
FORM A LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION FORM A
%90
121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds
Phone 425.771.0220 ft 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
(circle selected)
Gas # .......-Elec
#,_ —.Other:—
# CFM: <lOk_ >lOkLocation(s)
AC / Compressor /
Boiler / Heat Pump /
Gas #_Elec
#_Other:
_ # BTUs: <100k, 100k-500k, 500k-lMil
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 Bath #_Kitchen
#_Laundry
#,Other: #
duct)
Fireplace Gas # —Elec
#,...Other:,_W
# Location(s)__
Dryer Duct
Appliance Type
Appliance/Equipment Information (new and relocated)
Total #
AC Unit
BTUs:
Location(s) _Wv_
Furnace
BTUs:
Location(s):
Water Heater
BTUs:
Boiler
BTUs:
...... Location(s):......
Other:
BTUs:
Location(s): . . . . ..........
Fireplace/Insert
BTUs: ....... _---.
Location(s):„ m , .,.
Stove/Range/Oven
Dryer
...............
Outdoor BBQ
..w...............
_--
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 E]
Hydronic Heat in: Floor Wall E]
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
FORM A L:\Building New Folder 201000NE & x-ferred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014