20170411081544.pdfa DEVELOPMENT SERVICES
° �'`'�'t ''' RESIDENTIAL BUILDING PERMIT
APPLICATION
psi 1 alp 121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 4 Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDR , S Street Suite #, City State, Zip): Parcel #:
Subdivision/Lot #: Project Valuation: $
APPLICANT: Phone: Fax:
Address (Street, City Ze tate, Zip): l Main Address:
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PROPERTY OWNER: Phone: Fax:
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Address (Street, City, State, Zip): ® E-Mail Address:
LENDING AGENCY: Phone: Fax:
Address (Street, City, State, Zip):: E-Mail Address:
CONTRACTOR:* — Phone: Fax:
Address (Street, City, State, Zip): E-Mail Address:
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: .- AI'���
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PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: s . ft. Select Basement T e: Finished Unfinished
1" Floor: s . ft. Gara e/Car 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 LJ Retainin Wall: Yes 17 No 71
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 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 L:\Building New Folder 2010\DONE & x-ferred to LrBuilding-New drive\Form A2014.docx Updated: 1/17/2014