20170123162617.pdfn DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
i cl 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 ft Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PRO ""1 .D ESS (Street, Se # -City Slate Zip):
1
Parcel #:
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Subdivision/Lot #:
P�,je Val ti
: $
APPLICANT: i n
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Phone:
Fax:
Address (Street C111( tat , 7i
L
E-Mil Address,
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PROPERTY OWNER- ,... � � �,�
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Phone:
IQO& 3
� Fax:
Address (Street, City, State, Zip):
E-Mail Address:
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
E-Mail Address:
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Phone:
Fax:
Address (Str� t„ City, Staten Zl •
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E-Mail Addres
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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:
DETAIL THE SCOPE OF WORK: _ �._.�1t� )` _
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: s . ft. Select Basement T e: Finished Lj Unfinished
1" Floor: -sq. ft. Gara e/C ort: _ � ......... s . ft.
2" d Floor: _ _,., s . ft. Deck/Cvrd Porch/Patio: �s . ft.
Bedrooms # Full-3/4 Bath # Half -Bath # Other: _ s . ft.
Fire S rinklers: Yes No r
7 Retaining Wall: Yes No
Grading: Cut cu. yds. Fill cu.yds. Cut/Fill in Critical Area: Yes No 17
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 properly owner to submit a permit application to
the City of Edmonds. eP
Print Name: �. Owner Agent/Other 0 (specify):
r
SignativDate: 7,13 ,�~...:......_.
FORM A LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Fonn A2014.docx Updated: 1/17/2014