20161108161440.pdfCity of Edmonds
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 51h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 9 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: $
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APPLICANT: Phone: Fax:
y, State Zip): E-Mail Address:
Address Street City, t
P) `b"
PROPERTY OW ER: Phone: Fax:
Zq
t Address (Street, City, State, Zip): E-Mail Address:
LENDING AGENCY: Phone: Fax
Address (Street, City, State, Zip): E-Mail Address
CONTRACTOR:* Phone: Fax:
t .2'
Address (Street, t.`ly, State, Zip): l:-Niad Address:
WA State License #/Exp, l)-aw
*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:
.m DETAIL THE SCOPE OF WORK:, ice. ...__..,..t �✓p?w"�_.. .. ... _..
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: „ .. , - ws ft. Select Basement T e: Finished Unfinished
`l tatt . m_,.� �... .... _sq, ft. Garage/Carport: _.._- .. -... m.. _. -sq.ft.
2" Floor. _ � _ r...us . ft. Deck/Cvrd Porch_ /Patio: a............. �_.��; .� ft.
Bedrooms #„a , Full-3/4 Bath #,r Half -Bath # Other: _ _�aew.... _ s . ft.
Fire S rinklers: Yes Nor7 Retainin . Wall: Yes No
Grading: Cut cu. yds. Fill cu.yds. Cut/Fill in Critical Area: Yes L I No77
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):
Pant Name ...w
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Signature: / --_�� ......� III_µ_ __.�W- Date _ ._.—.....wa
FORMA L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014„docx Updated: 1/17/2014
