BLD20161586.pdfr.a
City of Edmonds
DEVELOPMENT SERVICES
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APPLICATION
1215 1h Avenue N, Edrnonds,8
Phone 425.771.0220 ft Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): I Parcel #:
Subdivision/Lot #: a Project Valuation:y �a
APPLICANT:Phone: Fax:
AA
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Address (Street, City, State, Zip): E -Mail Address: _
COW► C1p1-T
PROPERTY OWNER: Phone: Fax:
Ss CSG 912-823LI
Ac1c1racc (.ct%•fqq City glity, %ir)'I, _ E -Mail Address:
LENDING AGENCY: I Phone: 1I Fax:
Address (Street, City, State, Zip)„ I E -Mail Address:
CONTRACTOR:* IQ� EL Phone: Fax: ivh i IAS A 1�
Address (Street, City, State, Zip); E -Mail Address:
WA State License #/Exp. Date- �
*Contractor must have a valid City of'Edanonds business license prior to nO,
doingwork in the City. Contact the Ci Clerk's Office at 425.775.2525 sllicss Licrcnse #/Exp. Date:
Y City �� City li,tl�� • � � 2" /_'�a�
DETAIL THE SCOPE OF WORK 1!,,,+►..' +M..�'!_� S\ ��L\"' �'•'�./`' C3�
V►vtM•- '• v► C v .�.. o�:.v�. `��''a. .....__ .....
L • �d w� \ .... . �.. r0&01 ICT \L ----- -- --- 5 ... ... ......_... --u
PROPOSED NEW
Basement: —sq. fL
1" Floor:........ _, q. ft.
2"' Floor: .,. _— n N s . ft.
Bedrooms#,_,—,,, Full -3/4 Bath # „ Half -Bath #_m,_
Fire S rinklers: Yes No
GradinE: Cut cu. yds. Fill cu.yds
FOOTAGE FOR THIS PROJECT:
Select Basement Tvpe: Finished Unfinished
Gara e/Car ort: ----- �.. _....... .. _�..�s . ft.
Deck/Cvrd Porch/Patio:
��
Other �........ . .�..�_.�,___ S2.ft.
Retainin Wall: Yes No
Cut/Fill in Critical Area: Yes I 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 NFtmala �,_._��..... Owner ❑ Agent/Other ❑ (specify): 1
..:
Signature: .. .4.„ "" Date: ,�Z• Z�6
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FORM A LABUilding New Folder 2010\130NE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014