20200211112344'/Ic. 1% q k'
BUILDING PERMIT
APPLICATION P . r mi I =#:
Develonment Se ices
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.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 bring
electronic files on 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: q-4y-C! ja� V-\j
Parcel: () 0 L4 _1'_1 S 0 tO () 0 Le b LTO
Lot /Unit/Suite #: Subdivision:
PROPERTY WNER-
N e.
am n.
ddress.
V'J
Maili
City/State/Zip: VV
Phone #:?A M �6-2- �
Email:(� k.� —+e �\ kA a
5� �<(,A) �
OWNER INSTALLATION: *If yes, read anJ sign*
Will work be performed by the property owner? 0 Yes)(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 Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: kArAA&A "A31,-6 -2—
Mailing Address: JV-06A.J_&��
City/State/Zip:�_%fuf_+�_, VVA
Phone#- Lfq"— IA:::
E-mail:&JAJMq]Mh��. CA�
GENERAL CONTRACTOR: (if differ from applicant)
General Contractor: "A'b VVI
MailingAddress: A,�
,,� C
City/State/Zip: E;1VffCA- A
Phone#:
E-mail:
STATE UBI M Lk
CITY OF EDMONDS BUSINESS LICENSE #:0—
,WA STATE CONTRACTOR L & I M (CCB) & EXPIRATION DATE:
('WAE_AWtb1r11D11J rj'��J 7- 1
TYPE OF PERMIT (Novide
0 Accessory Structure/
Detached Garage
Details on Page 2)
0 Addition
El Demolition
• New Single Family / Duplex
Ymechanical
0 Plumbing
• Fire Sprinkler
11 Remodel
0 Re -Roof
• New Commercial/ Mixed Use
• Signs
0 Tank
• Tenant Improvement
0 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:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basemenl�ft: Finished 01,,,�hfinished 0
1st Floor, sq ft:
2nd Floor, sqft:
Garage/Carport:, sq ft:
Deck/Covere rch/Patio:
Other sq ft:
PROJECT DESCRIPTION
-IeVG�0(_ -�D OK
V\CA 0 &tf a-S
VYVA L1,
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 Namej:
Signaturx'r_4 F Date v I
I
GENERAL
O%��ancy Group(s):
COMMERCIAL DATA
Occupant Load�(s
Type(s) of Co uction:
Fire SXpr'ers: Yes El No El
WA STATE ENERGY rnD-. our projec ffects the building envelope,
mechanical systems, and/o h I g, you must complete the
g, yc
appropriate WSEC forms.
DEFERRED SUBMI�TTALS: ommercial bui_an�ermits that will require
associated plumbin�mechanical, fire sprinkler fire alarm
, alldkr
permits are ap P " d for s eparately.
TI / CHANG�F 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
Furnace
Y'_
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
PLUMBING FIXTURE
QtY
COUNTS (New, Relocated or re -piped)
QtY
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? Y or N
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
GAS/FUEL 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 GAS, AIR VACUUM COUNTS
(New, Relocated or re -piped)
MY Qty
Carbon Dib �e
Nitrou S'0'0�
Helium
,>�gen
Medical Air
Other:
Wa-I'Va c u u m Other:
DEMOLITION
Type of 11�� e to be demolished:
Square footage of stru�ctur �demo�ed_
AHERA Survey done :'Y'/__*� PSCAA Case #:
Critical Areas Petg'rmi nation:
Study Required [1 Conditional Waiver El Waiver El
Fill in kcyE] Fill Material:
Removal E] _'� ���Sieof
Tank (Gallons)
Critical Are etermination:
���Study Required 0 Conditional Waiver El Waiver El
G RADE/F ILL/ EXCAVATE
Grading: Cut cubic yarcls,"�
Fill cubic ya
Cut / Fill in Cr�ir,,. Yes El No E]
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.