20170124151256.pdfNo DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
1, it 121 5'h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220!k Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel #:
Subdivision/Lot #: 0 7 Project Valuation: $
APPLICANT: a 12— Phone:
Address, Street, City, State, Zip) E-Mail At dress:
7 �A LC
Ll (02J/"0,5-
PROPERTY OWNER: Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip). E-Mail Address:
CONTRACTOR:* 0 -2_1Z IZOC) P)2 r-N Phone- Fax:
Address (Street, City, State„ Zip): ,
E-Mail Address:
e' e�
L $2
WA State License 41E Date:
*Contractor must have a valid City of Edmonds business license prior to E�E -z' F-o'J711; 11 C�
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp.Obate:
DETAIL THE SCOPE OF WORK: d 1-
. ......... . . .
PROPOSED NEW S!2UARE FOOTAGE FOR THIS PROJECT:
Basement: ........ . ..... . . ..... ft. Select Basement Type: Finished Unfinished
10 lst Floor: Q,(V' Garage/Careort: ft.
'-2nFloor: sq. ft. Deck/Cvrd Porch/Patio:
Bedrooms # 7 Full-3/4 Bath # Half -Bath # Other: . ..... -sq.
Fire Sprinklers: Yes No Retaining Wall: Yes NoJ7
Grading: Cut cu. yds. Fill -cu-yds,TCut/Fill in Critical Area: Yes LJ Nol I
Ideclare 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 Ed onds.
Print Name -
Owner
,
Signature: Date:
19110 1
FORM A LABuilding New Folder 201000NE & x-ferred to L-Building-New drive\Form A2014.docx Updated: 1/17/2014