3466_001BUILDING PER
APPLICATI
Development Services
Building Division
121 Sth Ave N / Edmonds, WA 98020
425.771.0220
For handouts su bmittal requirements, permit status and Inspection
scheduling Information go to: www.edmondswa.gov.
PLE4SE 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 an a flash drive or coordinate for electronic transfer.
Please call 425-771-0220 to schedule an Intake appointmentl
JOB SITE INFORMATION/LOCATION- (Wh thework Is taking place)
Job Site Address: q,-9 f 5 � 7 A, C,
Parcel: CQ -AT,-3 t,�On co I. I q C1 r.) tz�)
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: . �C�\ V-\ �� I � C
Mailing Address:
City/State/Zip:
Phone #: o
Email:
OWNER INSTALLATION: *If yes, read and sign'
Will work be performed by the property owner? 0 Yes 0 No
I own, reside in, or wil I 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 Signature:
APPLICANT / CONTACT INFORMATION.
Name of Applicant: �& x r\ ,� i L
Mailing Address: q_ �Onk n
City/State/Zip: fy f,-
Phone it) ko - 0
E-malj:�2�� "Vt e-R9017krIv%_A� k-LP-�- Y\-4 - Cb1
GENERAL CONTRACTOR., (if different from applicant)
General Contractor Y\
Mailing Address:. q �p _z,
City/State/Zip: 4��V -A- W W C_ q
Phonet$�DTJ� - 9.46-- —JAIC)o
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
7 Permlt #:
mit
0 Accessory Structure/ 0 Addidon
Detached Garage
0 Demolition 0 Mechanical
0<ew Single Family / Duplex 9-Kumbing
• Fire Sprinkler Li Remodel
• New Commercial/ Mixed Use 0 Re -Roof
0 Signs 0 Tank
0 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.
Valuallion:
Basement sq ft;
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq it:
Deck/Covered Porch/Patio:
othersq ft:
Finished 0 Unfinished 0
I certify that the information I have provided on this form/applIcatlon 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. N
Print Namy4L,4 ft.—C . I
WASTATqCONTRACTORL&I#:(CCB) EXPIR TIONDATE:
9
GENERAL COMMERCIAL DATA
Occupancy Group(s): Occupant Load(s):
Type(5) of Construction: Fire Sprinklers; Yes D No 11
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
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
BTUs Gas Elec other Qty
A/C Unit /Compressor
Air Handier /VAV
Boller
Dryer Duct
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions If a Commercial Bldg)
Other:
PLUMBING FIXTURE COUNTS (New, Relocated or re -piped)
- -_ Qty Citly
Clothes Washer Tub/ Showers
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/sink
Refrigerator Water Supply
Hose Bibs
Water Heater -Tankless? YoUN
HVdronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
GAS/FUEL CONNEcrION COUNTS (New, Relocated or re -piped)
BTUs Qty BTUS Qty
A/C Unit
outdoor BBQ/ Fire pit
Boller
Stove/Range/Oven
Dryer
I
Water Heater
I
Flrdplacel Insert
Other;
Furnace other:
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or re -piped)
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:
AHEIRA Survey done? Y / N I
PSCAA Case 4:
Critical Areas Determination:
Study Required 0 Conditional Waiver ED Waiver DO
U
0
Fill In Place C3 Fill Material: ---
Removal 11 Size of Tank (Gallons)
Critical Areas Determination:
Study Required El Conditional Waiver Waiver El
GRADE/FILL/EXCAVAI
Grading: Cut cubic yards
Fill cubicyards
Cut/ Fill In Critical Area; Yes0 No 11
GENERAL PROVISIONS
APPLICATIONS: Applications are valid for a maximum of I 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.