20161222122305.pdffit'" LL7 bf,r�
a� DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
r.s•t 121 5"' Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 A Fax 425.771.0221
PLEASE RE'F'E'R TO THERESIDENTIAL BUILDING CHECKLIST
FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
Suhdivis' Al/'j1 r S'"�Lt ;�J
YC/ scu
Project Valuation: $ 1 tq �o
APPLICANT:
16- L
Phone: Fax:
2o6 -3Y(-6767
Address
ZStreet, tt �la f ' y � Ai1
a,
E-Mail Address;
PROPERTY OWNER-
Ili
Ph Fax:
Addre. treet, City, State Zip):
E Mail Address;
L S
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:*,Q�C.<7/li �.LL
Phone: Fax:
Acldres St ect, C' Ae Gee
s tr , "'Stale,` "Ip )l
E-Mail Address:
6 6 l o CO
WA State Licensc 11/I:xp. Date:
:'Contractor must have a valid City of Edmonds business license prior to 6; & 6 YOC 1
doing work in the City. Contact the Wiry Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK:..-._-.
......... ......................
PROPOSED NEWS UARE FOOTAGE FOR THIS PROJECT:
Basement: s . ft.
Select Basement Ty e: Finished Unfinished
I" Floor: _ m ......sq, ft.
Gara e/Car ort: ._ .....-
2"' Floor: ., .....___-_....... ....... . a - _rs . ft.
Deck/Cvrd Porch/Patio:
Bedrooms # Full-3/4 Bath # Half -Bath #
Other:_ ... ......,s . ft,
Fire Sprinklers: Yes No
Retainin Wall: Yes No
Grading;: Cut _cu. yds. Fill _ cu.yds,
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 properly owner or duly authorized
agent of the properly owner to submit a permit application to
the City of Edmonds.
Pant Name: .._......_�� ... ... i t' ......
Owner A ent/Other y):......_...._,__ ._
g' (specify):
L
? 2_.. l�
Signature:
.... ............
9
FORMA L:ABuilding New Folder 2010\DONE: & x-fer red to L-Building-New driveAForm A2014.docx Updated: 1/17/2014