20161201112106.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
�APPLICATION
121 5`h 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
PROJECT ADDRESS (Street, Suite #, City State, Zile): Parcel #:
Subdivision/Lot #: Project Valuation: $ t L',G yo /_
APPLICANT: •,f� Ga��l�rwcF�`� co Phone: Fax:
'
,o6 6o 1 066
(Street, City, State, Zigtl; ], �wltti'l Address: /�
S�t{s� tte �6 �vuuerCO^SiI (104. CrJ
PROPERTY OWNER: Phone: Fax:
8 ,r r-_\ J06-�;"5- Oy3 3
lw��yt Address
( y" "'4t;at� , lip): E-Mail Address:
S', Cit
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
CONTRACTOR:* Actue Ca Phone: _ Fax:
Address (Street, City, State, Zip): F-Mail Address:
WA State License ll/Exg,), Date:
*Contractor must have a valid City of Edmonds business license prior to 0 k C 0 0 6
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business 1,'i nse #/Exp. Date:
DETAIL THE SCOPE OF WORK .. _ ..T��A� s.1.(_..... v\.tu Relcj
PROPOSED NEW SQUARF FOOTAGE FOR THIS VRoj :C°I"':
Basement: ft. Select Basement T 2 pe. Finished Ll Unfinished
1" Floor: w— .. _- ------ ft. (3ira Ee/Car or t:. �..... � �� �_ �.. ,. �s(I , ft
,"t Floor: _..... _ st' . ft. Deck/Cvrd Porch/Patio: .� ... _...... .. t . ft.
Bedrooms #
.._.-. Full-3/4 Bath # Half -Bath #...eee_._ Other:....... ------- _...--.-.n
. ft.
Fire Sprinklers: Yes n Na Retaining Wall: Yes No
Grading: Cut w ,,,_w, ._ cm ytl�s. Fill w cu.y(k Cut/Fill in Critical Area: Yes 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. I 1
Print Name: �m � .t ..._. .. ?_ t" Owner 0 Agent/Other (specify):._�O'A T� f `"r
Si nature: , t�a
g "'""" - ., ^€'��°� . ..— Date:
c?e0
007
FORM A L:\Building New Folder 2010\DONE & x-ferred to L-Building-New drive\Form A2014.doex Updated: 1t17/2014