20200117120707BUILDING PERMIT
APPLICATION rp.rmit #:
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
C) rj 425,771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edmondswa.gov.
PLEASE NOTE: Intake appointments are required for New Single Family
Residences, Large Additions, ADU's, New Commercial, and Mojor 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 call 425-771-0220 to schedule an intoke appointment!
JOB SITE INFORMAT19V/LOCATION: [W
L_Ieqt_he work
Job Site Address: I I (� 2 S
Parcel: ob�) qs'—, 0 V__A 0 0 DJ
Lot /Unit/Suite #: Subdivision:
PROPERI
Name:
Mailinj
City/St
Phone
Email
OWNER I
Will work be performed by the property owner? 13 Yes No
I own, reside in, or will reside in the completed structure.' �his
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/ CONTAC INFORMATION:
Name of Applicant:17.1 0 0 a K)�Qyl ('2-
Mailing Address: vu,/U0
4,1 U
City/State/Zi�: A cl & '
Phone 4
E-mail: V—Ck; HA.0_0( IC-1
GENERAL CONTRACTOR: (if different from appli
General Contractor: r NA ck�
Mailing Address: rk c
City/State/Zip:
Phone : Ll 1-� - -2A-C"('
E-mail: LA V\ 11 A -f _4k�g V
STATE LIBI #: c.
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
() `�_ I kA I 1Z_ I
TYPE OF PERMIT (Provide
0 Accessory Structure/
Detached Garage
Details on Page 2)
El Addition
El Demolition
echanical
,*New Single Family / Duplex
0 Plumbing
• Fire Sprinkler
0 Remodel
• New Commercial/ Mixed Use
El Re -Roof
• Signs
0 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,
and the profit for the. a k indicat d this application.
I
Valuation: c)
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finishe"15( Unfinished El
1st Floor, sq fit:
Lp --> I
2nd Floor, sqft:
� Ps—
Garage/Carport:, sq ft:
�j
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT DESCRIPTION
VT
I 0�'b '\/ ,--
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 prop owner to submit a permit application to the City of
Edmonds.
Print Name- �AuvvQ_-
Signature: Date
GENERAL COMMERCIAL DATA
Occupanc G up(s): Occupant Load(s):
Type(s) of Con :t r - cl�_-
Fire Spr�i�4rs: Yes D No E]
WA STATE ENERGY CODC 'o u..r. proqr-, Iding envelope,
mechanical system , , dl. g Y
appropriate WSEC fo rms. �� ou must complete the
DEFERRED SUB�MITTALS: commercial bu g permits that will require
associated plum I g, mechanical, fire sprinki r).�Zd/or fire alarm
s
permits are led for separately.
TI CHA�E OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
BTUs Gas / Elec Other QtY
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
[A_
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
PLUMBING FIXTURE COUNTS (New, Relocated or re -piped)
Cit Qty
Clothes Wa\,h
Tub/ Showers
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
\Rqssure��ction/ Regulator Valve
Floor Drain/Sink
Re tor Water Supply
Hose Bibs
Water Heater Tankless? Y or N
Hydronic Heat
Water Service Line\
Sinks
Other:
Toilets
Other:
GAS/FUEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BT
A/C Unit
Outdoor BBQ / F
Boiler
N,
Stove�/ge/Oven
Dryer
ter Heater
Fireplace/ Insert,
Other:
Furnace /
Other:
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or re -piped )
City Qty
Carbon Dioxid e
Y&rous Oxide
Helium
><
Oxygen
Medical Air
Othe"'*_�
Medical - Su rF acuum Other:
'��l V
DEMOLITION
Type of struc ;` to be demolished:
Square footage of struct 6e demolished:
J
AHERA Survey don6? Y N
It!,Case #:
Critical Areas Determination:
Study Required El Conditional Waiver El Waiver El
Rill in Place EEI 'RM*WMAt!!� a 1:
Removal El
of Tank (Gallons)
Critical Areas Determ adIt'i'on:
quired 0 Conditional Waiver Waiver El
Study =
GRA DE/F ILL/ EXCAVATE
Gradi4.'Cut cubic yard
Fill cubic �al 'A
Cut/ Fill in Critical Area-. Yp No
GENERAL PROVISIONS
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.