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20161215153940.pdfUA ^p I DEVELOPMENT SERVICES RESIDENTIAL BUILDING PERMIT APPLICATION 121 5`h Avenue N, Edmonds, WA 98020 City of Edmonds Phone 425.771.0220 # 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: $ IL 1� C) - . 1 APPLICANT. Fax: � � � 1 E1�rt1c.� Address Sheet, City, State ip): ry E-Mail Address: PROPERTY OWNER: Phone: Fax: Address (Street, City, State, Zip): E-Mail Address:: LENI.) G AGENCY; Phone: Fax; A(I ^s (Street, City, State, Zip): E-Mail Address; (;<' NTk , I)R:* + Phone: Fax: „,W , Address (Street, City, State, Zip): E-Mail Address: 0 0 P 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: L"t b DETAIL THE SCOPE OF WORK _��'"� """' PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT: Basement: s . ft. Select Basement T e: Finished Unfinished 1" Floor: s . ft. Gara e/Car ort: _ . ft. 2"' Floor: s . ft. Deck/Cvrd Porch/Patio: �,.... . s . ft. Bedrooms # Full-3/4 Bath #n_ Half -Bath #w.... Other , _......... sq. ft. Fire Sprinklers: = No Retaining Wall: Yes No 17 Gradillg: Cut -su. Y(k 1411 cti.y(Is. I Cut/Fill in Critical Area: Yes No7. 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: Av t �1 .... Owner ❑ Agent/Other © Pecify)• Signature: _. -------- Date: FORMA LABuilding New Folder 201 HONE & x-ferred to L-Building-New drive\Form A2014.doex Updated: 1/17/2014