20170119160454.pdfDEVELOPMENT SERVICES
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RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds
Phone 425.771.0220 Ik Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PTi, ' (Street Suite #, City Stat Zip): Parcel #:
Subdivision/Lot #: Project Valuation: $
APPLICANT:
N
Adt t,sMSticcl City State, Zt;r';
PROPERTY OWNER:� !
�� lT t
Aquft (S.treet, City, StaZt 2ip):
LENDING AGENCY:
Address (Street, City, State, Zip):
CONTRACTOR:*
Address (Street, City, State, Zip):
*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
E-Mail Address:
Phone:
E-Mail dress:
Phone:
E-Mail Address:
Phone:
E-Mail Address::
WA State Licrj'i
s License
Fax:
Fax..
Fax:
t -p to
DETAIL THE SCOPE OF WORK:.�
n
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: -Sq. ft. Select Basement Type: Finished LJ Unfinished
I" Floor: ........... _ ........ _s . ft. Gara e/Car ort: . w ._ _ _._... m s . ft.
2° Floor: _ .. .........s . ft. Deck/Cvrd Porch/Patio: W_ _ _ s . ft.
Bedrooms # Full-3/4 Bath # Half -Bath # Other __.......,. _ s . ft.
Fire S rinklers:Yes No Retainin Wall: Yes No
Grading: Cut . ........ --cu. yds. Fi11 .....cu.yds. I Cut/Fill in Critical Area: Yes No _w
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: °,:... Owner ❑ Agent/Other (specify); '
Signature: Date: ,. ..:�.. � . �.,,..�.�...........
FORM A LABuilding New Polder 2010\DONE & x-(erred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014