20170103143113.pdfI D t J
t DEVELOPMENT SERVICES
14,
67 RESIDENTIAL BUILDING PERMIT
� APPLICATION
r� 121 51h Avenue N, Edmonds, WA 98020
City of°Edmonds Phone 425.771.0220 It Fax 425.771.0221
PLEASEREFER TO THE RESIDENTIAL, BUILDING CHECKLISTFOR OR SUliM17TAL REQUIREMENTS
PROJECT ODILESS (Stre t Suite It, City state, '4il))
Parcel #:
11
Subdivision/Lot #:
Project Valuation: $
�OU
/
APPLICANT:
➢drone: Fax;
Address (Street, City, State, Zip): J
E-Marl Address:
PROPE'1a 1 OWNER, ,
Phone:L911
Address (St1eel, City, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone. Fax:
Address (Street, City, State, Zip):
E-Mail Address:
CONTRACTOR:* 1"OR:*
Phone: Fax
Address (Street, City, State, Zip);
E-Mail Address:
WA State License ll/l,x °ro D I t:
� 2S ,
/1/143W �. p'"
"Contractor must have a valid City of Edmonds business license
prior to I t {)
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City I usiness L w �nse 4/Exp. Date:
0'2--' rf� /'
DETAIL THE SCOPE OF WORK ..
_ . _
®. . . ..........
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement_: ., _... _ __s . ft.
Select Basement Type: Finished Unfinished
l" Floor: .... ........ .. s . ft.
Gara e/Car ort -. sc ....ft.
2" Floor: ..... ..M . ._ .1..1..1 ..st . ft.
Deck/Cvrd Porch/Patio: sar 1t.
Bedroorns # . .... Full-3/4 Bath # Half -Bath # , „ ,aW
Other m.. . ,,,_ _ sq. ft.
Fire S rinklers: Yes No
Retainin Wall: Yes No
Grading: Cut `—cu. yds. k ll cu.ycls.
Cut/Fill rn Ctttical 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.
7 r
Owner ❑ Agent/Other (specify) ...m,.w,........
Signature: r .....
Date:
FORMA L:ABuilding New Folder 2010\DONE & x-(erred to IL -Building -New drive\Forni A20I4.docx Updated: 1/17/2.014