BLD20161344.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
"S1
1215"' Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADD ES (Street, Suite #, City State, Zip):
7-7o-? 1 t `� f S W X1,.4 �� S 1,✓/} YU2 6
Parcel #:
00(9 41 5 Ovo 0 0 2 c`JO
Subdivision/Lot #:
Project Valuation: $ O V
APPLICANT: �f
MG� iq 9
Phone: Fax:
�L-.7-1.9 aVS—
A�css Street, City, State, lap):
-MallAdd s:
y 9�
PROPERTY OWNER:
CtsM A J n,tj- �" � �1�F j LLC
one: C14246 I Fax:
)C -Q. s'4 - _r ' �, , wM
Address (Street, City, State, Zip) ^
Le�� LyC4 Rk—A SC LGtCC wfl' -10��
E --M1 �-1lail Addre s: 1
td,0.-1dtk wt4� / fro"
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip);
E -Mail Address:
CONTRACTOR:* CR A�_
Phone: Fax:
ss tree
Addre,S t, Cit 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: 1`' �' I '
kte►' �p �4 C �M�.a l 121X 1i 1
PROPOSED NEWS UARE FOOTAGE FOR THIS PROJECT:
Basement: s . ft.
Select Basement Type: Finished Lj Unfinished
I" Floor: sq. ft.
Garage/Carport: sq. ft.
2" Floor: sq. ft.
Deck/Cvrd Porch/Patio: 1 i s . ft.
Bedrooms # Full -3/4 Bath # Half -Bath #
Other: sq. ft.
Fire Sprinklers: Yes 17 No
Retaining Wall: Yes NoLj
Grading: Cut cu. yds. Fill cu.yds.
Cut/Fill in Critical Area: Yes Lj 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: 4 e
Ownergent/Other ❑ (specify): _ ......
Signature: 't WWW
Date:.-.�L�
FORM A LABuilding New Folder 2010\DONE & x -l` 111 to L -Building -New drive\Form A2014.docx Updated: 1/17/2014
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Property Line
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PropertyOwner:
Property Address: '�� Z,Q-0 S"f ,
Zone: