APPLICATION.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
i APPLICATION
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
PROJECT ADDRYLSS Street Suite 11, ("ilr ."late, lip): /� Parcel #:
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wtt Clivi 4it+n 1, of #: Project Valuation: $ f 1
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APPLICANT: 1Phone: Fax:
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Address (Street, City, State, Zip): E -Mail Address:
51
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PROPERTY OWNER: Phone:Fax:
blz r_ J"cit S '133-6 C
Address (Street, City, State, i E -Mail Address:
LENDING AGENCY: IfPhone: Fax.
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* Phone: Fax:
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Address (Street, City,`tate, Zip): E -Mail Address:
3215 149 5-t ermf
A St�" .."cef�. ^ # l.�xp. Date:
*Contractor must have a valid City of Edmonds business license prior to � "� � , , , f
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City 1 p Date.
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PE OF WORK:
DETAIL THE SCOy�� 2 1 C d-1 ifs Q ... ..._ .••
�D
PROPOSED NEWSQUARE FOOTAGE FOR THIS PROJECT:
Basement: sq. fto Select Basement T e: Finished Unfinished
I" Floor: _ ......_..W -s ft. Gara e/Car ort: _. .. ...... ....... sq. ft.
2 n Floor: ...w..... ...—_ s . ft. Deck/C_ vrd Porch/Patio:
_
Bedrooms # Full -3/4 Bath # Half -Bath -Bath # Other: _ -w,a.._ sq. ft. . _�..,,. .......m
mm.Y�
Fire S rinklers: Yes Nol-7 Wall: Yes NoEl
Grading: Cut cu. ds. 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.
e .w!.y.. 0 ` _ Owner ❑ Agent/Other (specify) ....�.e, u
Print Name .,,... .,,,m...
Signature: ...... Date_: _-
FORMA LABuilding New Folder 2010\130NE & x-ferred to L -Building -New drive\Form A2014,docx Updated: 1/17/2014