3467_001BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 Sth Ave N / Edmonds, WA 98020
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 Major Tenant
Improvement application submittals. if plans are prepared by a profession-
al, electronic files are requested In addition to the hard copies. Please brInR
electronic files an a flash drive or coordinate for electronic transfer.
Please call 425-771-0220 to schedule an Intake appointinentl
JOB SITE INFORMATION/LOCATION: (Villere the work Is takIng place)
Job Site Address: q "3P 3f Ck A�
Parcel: C)C) '�,q Ll IDC9�1 Q 1 0 1 C) C��
Lot /Unit/Suite #: el 0 \ Subdivision:
PROPERTY OWNER:
Name: Q %
Mailing Address:
Clty/State/Zip:
Phone It: A0 —T
Email:
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? 0 Yes 11 No
I own, reside In, or will reside in the completed structure. This
installation is being made an 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& L Y-X NA—n
MailingAddress:
S41
City/State/Zlp:--�-D Q, L"X. L
Phone 1:
V\ IA 0-�n
GENERAL CONTRACTOR: (if different from ap 11 nt) M Vy)
General Contractor: Yl it ft yu�—
Mailing Address: �A �.C) � S �
city/state/zip. a W <L1 q e I ko (5
Phone it- auo C) c)
E-mail: P I;__)b'C &AkA'V1 ka't\
STATE UBI #: -(/-7Q9- (�>`U S(0(,:.'=,
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CO TRACTOR L & I #: [CCB) & EXP TIOT DITE:
rA qq I
Perrdt
IYIIE 01; PI:HMIT (11iovide f)ctcAs on Page 2)
0 Accessary Structure/ 0 Addition
Detached Garage
11 Demolition
1:1 Mechanical
LAew Single Family/ Duplex
cr-pli'u' mbing
• Fire Sprinkler
0 Remodel
• New Commercial/ Mixed Use
0 Re -Roof
• Signs
0 Tank
OTenant Improvement
11 Other
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (rounded to
tho nearest dollar) of all equipment, materials, labor, overhead,
and the profit for the work InqIcoted on this application.
Valuation: I Oblb"A
mi o i)os Ia. I i N E W SCII JAR F V 00TAG E 170 R TI I IS AP P I -I CATIO N
Basement sq ft: Finished 0 Unfinished 0
1st Floor, sq ft:
2nd Floor, sqft:
Garage/Carport.-, sq ft;
Deck/Covered Parch/Patio:__
Other sq ft:
PR OJ ECT D ESCRI PTI 0 N
C C-
I certify that the Information I have provided on this form/application Is true,
correct and completeo and that I am the property owner or duty authorized
agent of the property owner to submit a permit application to the city of
Edmonds.
Print Name: k Vy\
GENERAL COMMERCIAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes 11 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
MECHANICAL EQUIPMENT COUNTS (Nevi and Relocated)
BTUs Gas Elac Other City
A/C Unit /Compressor
Air Handier /VAV
Boller
Dryer Duct
ExhaustFans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions If a Commercial Bids)
other:
PLUMBING FIXTURE COUNTS (Nevi,
Relocated or re-pipud)
City
QtY
Clothes Washer
Tub/ Showers
Backflow Device (RPBA, DCDA, AVB)
Dishwasher
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
r
Water Heater - Tankless? Y oCN
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
GAS/FUEL CONNECHON COUNTS (New, Relocated or re -piped)
BTUs Oty BTUs Qty
A/C Unit
outdoor BBQ/ Fire pit
Boller
Stove/Range/Oven
Dryer
Water Heater
Firdplace/ Insert other:
Fumace other:
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or ro-piped)
City
Cairbon 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 #:
Critical Areas Determination:
Study Required 0 Conditional Waiver Waiver L1
il�
-
Fill in Place 11 Fill Material:
Removal
(Gallons)
Critical Areas Determination:
I 5tudyRequiredl] Conditional Waiver El Waiver[]
GRADE/FILL/EXCAVATL
Grading: Cut cubic yards
Fill cubic yards
Cut Fill In Critical Area: Yes 0 No 0
GENERAI I'ImVISIONS
APPLICATIONS: ApplIcaUans 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.