4355_001Io C. I % q v
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:
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
elprtrnnir. files nn a flash drive or coordinate for electronic transfer.
Please call 425-771-0220 to schedule an intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: '77.;'� —90--2
Parcel:
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: _JA "4,
MailingAddress: 71��3
City/State/Zip: Z'Mo-lo-za A '94'20.-)
P h o n e #: 0-3 9 Z
Email:
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? VIYes I] 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 sale, lease, rent, or exchange according to RCW
18.27.090.
Owner SigisatureA
APPLICANT/ CONTACT INFORMATION:
Name of Applicant: A's Ago V e_
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
GENERAL CONTRACTOR: (if different from applicant)
General Contractor:
M a i I i n g Ad d ress: ?- 1.5—b -7
city/state/zlp�
Phone #: 3,213)
E-mail: C L, / ->j r,, z Z - r-nV s 4 r , 4 , e-
STATE UBI #: Ll
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION PATE:
Oc —1
=rmit #:
;0=
TYPE OF PERMIT (Piovide Details on Page 2)
El Accessory Structure/ dclition
Detached Garage
El Demolition
0 Mechanical
El New Single Family/ Duplex
0 Plumbing
EI Fire Sprinkler
0 Remodel
EI New Commercial/ Mixed Use
0 Re -Roof
0 Signs
El Tank
El Tenant Improvement
El 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,
andtheprofit_fort� �prlinclicote n this application.
Valuatl
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished EI Unfinished El
Ist Floor, sq ft:
2nd Floor, sqft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
other sq ft:
PROJECT DESCRIPTION
I certify that the information I have provided an this form/application is true,
correct and complete, and that I am the property owner or duly authorized
agent ofthe property ownerto submit a permit application tothe City of
Edmonds.
P nt Name:
Date 311'01z,�
GENERAL COMMERCIAL DATA
Occupancy Group(s): Occupant Load(s):
GAS/FUEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fi pit
Type(s) of Construction: Fire Sprinklers: Yes 0 No El
Boiler
Stove/R I" verl
WA STATE ENERGY CODE: If your project affects the building envelope,
mechanical systems, and/or lighting, you must complete the
appropriate WSEC forms.
Dryer
W/ar Heater
DEFERRED SUBMITTALS: All commercial building permits that will require
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
Fireplace/ Inse rt
__z
X
Other:
TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
BTUs Gas Elec Other Qty
Furnace
MEDICAL
11
Other:
GAS, AIR VACUUM COUNTS
(New, Relocated or re -piped)
Qty
Qty
Carbonzl.xide
Nitrous Oxide
A/C Unit /Compressor
H 4urn
Oxygen
Air Handler /VAV
'/7
V Medical Air
/
Other:
Boiler
�)
/
Me �ic- Sur Ical Vacuum Other:
DEMOLITION
pe of r t be demolished:
f
4a �e structure to be demolished:
Dryer Duct
Exhaust Fans
Fireplace
Furnace
A "RfAu y done? Y / N
PSCAA Case #:
Heat Pump Unit
C i as Determination:
Study Required El Conditional Waiver El Waiver El
Fill in Place Fill Material:
Removal El TSize of Tank (Gallons)
Critical Areas Determination:
Study Required El Conditional Waiver El Waiver El
GRAD E/F I LL/EXCAVATE
Grading: Cut cubic yards
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
PLUMBING FIXTURE COUNTS (New, Relocated or re -piped)
Aty Qty
Clothes Washer
Tub/ Showers
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
-
Fill cubic yards
Drinkii Fountain
Pressure Reduction/ Regulator Valve
-
Cut/ Fill in Critical Area: Yes 11 No El
GENERAL PROVISIONS
APPLICATIONS: Applications are valid for a maximum of 1 year.
ESLHA Applications, 2 years.
96/Ir Drain/Sink
Refrigerator Water Supply
-
Hose Bibs
Water Heater - Tankless? Y or N
Hydronic Heat
Water Service Line
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.
Sinks
Other:
Toilets
Other: