20161114141158.pdfz DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
"St tl�tt, 121 51h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 f Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
I'IlfbId(",""l t,t��.t Suite #, City State, Zip):
Parcel #:
"ADDRESS",
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Subdivision/Lot #:
Project Valuation: $
APPLICANT:
Phone: Fax.;
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Address (Street, City, State, Zip):A
Address:
1 l�vi �V^ W� P
�[E-Mail
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PROPERTY OWNER: Phone: Fax;"
AddreStreetCity, State, Zip):
ss (,0e
E-Mail Address.
tA�";
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LENDING AGENCY:
Phone: Fax
Address (Street, City, State, Zip):
E-Mail Address::
CONTRACTOR:*
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
WA State Licete(Illf l ,:�m
*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 )�1�,x g, Date,
DETAIL THE SCOPE OF WORK ,1w'
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: tit,ft,
Select Basement Type: Finished Unfinished
1"Floor: " _.. ..w"...__ _ — .. st. ft.
.itttage/Cap° ort: .....�..... t'. ft.
Floor: _..__.� .,...... _.......tit . ft.
Deck/Cvrd Porch/Patio:
Bedrooms # Full-3/4 Bath # Half -Bath #
Other: m ...._ �-m- -'st , ft.
Fire Sprinklers: Yes r7 No
I °Marlin Wall: Yes No
('Arading: Cut" _ -cu. yds. Fi111O,.,,,, cu, ds.
Cut/Fill in Critical Area: Yes LJ 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: 1w �..._.
Owner ❑ Agent/Other ❑ (specify):.°...,
�r. eeem
�_—w........,,
Signature:�
Date: �....��_�
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FORMA L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014,docx Updated: 1/17/2014