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BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave IN / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: httj�j %vLk-
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
JobS!teAddress: U--CA 1-7C-4-�' PL
Parcel: QQ 4-1 '1 "(CX)V 0 e) (o V G
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name:
LD ��i WILO
0 Accessory Structure/ 0 Addition
Detached Garaee I
0 Demolition 1 0 Mechanical
El New Single Family / Duplex El Plumbing
• Fire Sprinkler [3 Remodel
• New Commercial/ Mixed Use D Re -Roof
D Signs
j EI Tenant Improvement El Other
MailingAddress: 14:� ?-'�; ?,� T-, !�j -
City/State/Zip: P?01-e
WA cl'�m
Phone #: +2 �i - 1�fl
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OWNER INSTALLATH)N: $If yes, read and sign*
Will work be performed by,the property owner? 0 Yes n No
I own, reside in, or will reside in the completed structure.
This installation is being made on property that I own which is
not intended for sal�e, lease, �rent,exchhange according to
RCW 18.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: A)'4o,&'g
Mailing Address: 4-�b 5- SE -; � -I--
City/State/Zip: _W-, U44 Cis' CO -
Phone #: QS - &0 - S611 -S
E-mail: cf&�t Cl; il'la i
GENERAL CONTRACTOR: (if different from applicant)
General Contractor:
—1
Mailing Address:_z,
City/State/Zip: 10
Phone If: -7
E-mail: LA 4 1 WtA Q UckkQ.(�ffM
71,i. )— 7n
WA STATE CONTRACTOR L & I # (C ) & E&RATION DATE:
U1,133 V(--A 37 0 F 7-L P,
CITY OF EDMONDS BUSINESS LICkNSE #: W--0-LS-09B
Remodel Permit fees are based on:
The value at the work performed, Indicate the value (rounded I
the nearest dollar) of all equipment, materials. labor, overhead,
and the profit for the work indicated on this application.
Valuation:
A/)/-- -
I certify 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 prop" owner to submit a permit application to the City of
Edmonds.
Print Name;.
Signature: Date