FIR2020-0025-APPLICATION", C. 1 b_y -
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edmond5wa.gov.
PLEASE NOTE. Intake appointments are required for New Single Family
Residences, Large Additions, ADU's, New Commercial, and Major Tenant
Improvement application submittals. If plans are prepared by a profession-
al, electronic files are requested in addition to the hard copies. Please bring
electronic files on a flash drive or coordinate for electronic transfer.
Please call425-771-0220 to schedule an intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: L,LQAv1 Ave y
Parcel: V ti Z DU s I
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Z
Name: n
Mailing Address: (.2
City/Stat Zip:
Phone #:� 2i \1 1_ �►
Email: �
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ Yes No
I own, reside in, or will reside in the completed structure. Thi
installation is being made on property that I own which is not
intended for sale, lease, rent, or exchange according to RCW
18.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name
Mailing
City/Sta
Phone #
E-mail:
GENERALI
General Contractor: -SW" G oks OND OI`
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI #:�j``
CITY OF EDMONDS BUSINESS LICENSE #: NIVI.- �q
A S,^CO T � T�OR�; t t ; (CC!0,61A
EXPIRATION DATE:
Y, S V tI'N�11
Office Use Only
TYPE OF Details on Page
❑ Accessory Structure/
Detached Garage El Addition
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
❑ Re -Roof
❑ Signs
Tank
❑ Tenant Improvement
❑ Other
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (rounded to
the nearest dollar) of all equipment, materials, labor, overhead,
and the profit for the work indicated on this application.
Valuation:
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sqft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
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 property owner to submit a permit application to the City of
Edmonds.
Print Name: 1
41
Signature:
�� Date�LkI101
COMMERCIALGENERAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes ❑ No ❑
WA STATE ENERGY CODE: If your project affects the building envelope,
mechanical systems, and/or lighting, you must complete the
appropriate WSEC forms.
DEFERRED SUBMITTALS: All commercial building permits that will require
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet
EQUIPMENTMECHANICAL •
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor
Air Handler/VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE ..r re-piped
Qty Qty
Clothes Washer Tub/ Showers
Dishwasher Backflow Device (RPBA, DCDA, JAVB)
Drinking Fountain Pressure Reduction/ Regulator Valve
Floor Drain/Sink Refrigerator Water Supply
Hose Bibs Water Heater - Tankless? Y or N
Hydronic Heat Water Service Line
Sinks Other:
Toilets Other:
GAS/FUIEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
Other:
MEDICAL•
(New, Relocated or .•.
Qty Qty
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum
Other:
DEMOLITION
Type of structure to be demolished:
Square footage of structure to be demolished:
AHERA Survey done? Y / N
PSCAA Case #:
1-01 rvedb ueEermmarnon:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place Fill Material: TwAkt S
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
APPLICATIONS: Applications are valid for a maximum of 1 year.
ESLHA Applications, 2 years.
LICENSING: All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & Industries and have a
current City of Edmonds Business License.
BID LOCATE SOIL SAMPLES
RESIDENTIAL
+�LCOMMERCIAL
RECORD SEARCH COMPLETED PLIA C� � � �� � oP�i}
NAMEttiI1��• G Q,` J DATEn wgill, all
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SITE ADDRESS lam` �21 t0*/% A W ZIP
1 Ir1 r` r/� 1 a w .
Mt1&-
PHONI
EMAIL
TANK SIZE" c, p,i FILL PIPE t �DIAMETER `
TOTAL �� z
FILL GRADE 4S LENGTH Sf-T GROUND COVER 6Qns'�
CONTENTS: OIL _ WATER OTHER TOTAL'
OFFICE NOTES:
FIELD NOTES: ep FIu-
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C,L. )j, -'L'1
ANIMALS Y0 VACAN N WATE6A POWER Y N NO PARK SIGNS Y/�y
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LINEWORK Y/N GDREMQVE
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'ID COMPLETED BY: i`�� ,, 1,,, JOB COMPLETED BY:
ite info taken by: U Yl�� Deadline: , Inv
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