3698_001Ti �A
,IV. I is 7
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: www.edmondswa.gov,
PLEASE NO 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 nash drive or coordinate for electronic transfer.
Please call 425-771-0220 to schedule an Intake appoIntmentl
JOB SITE INFORMATION/LOCATION: [Where the work Is taking place)
Job Site Address: . '90 Z D 2111-444, PI
Parcel: 003 B (ac)63 0 c).?t) ?
Lot /U n it/Su Ite #: Subdivision:
PROPERTY OWNER:
Name: A?.) 00 oun KeS-
Mailing Address: 2?0 2x z� 1-4 f�% P f s W
City/State/Zip: ECk M 0, Kd S g JAIA L718 0 2-4P
Phone#: 2-D(9-2-35—;9w5;?
Email:
OWNER INSTALLATION: "If yes, read and sign*
Will work be performed by the property owner? 0 YesX 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:
MallingAddress:
City/State/Zlp;1D)AASA�, WA Mb
Phone#:
E-mail:
—
GENERAL CONTRACTOR: (if different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI M
CITY OF EDMONDS BUSINESS LICENSE M W\� - 02 �0 I t P
WA STATE CONTRACTOR L & I #: �CCB) & EXPIRATIPN DATE:
Ac,)-T WW
'FE LM35
Per "ittv 7
TYPE OF PERMIT (Provide
Details on Page 2)
11 Accessory Structure/
Detached Garage
0 Addition
0 Mechanical
• Demolition
• New Single Family/ Duplex
_�lu bing
J(
• Fire Sprinkler 0 Remodel
11 New Commercial/ Mixed Use EI Re -Roof
EI Signs 13 Tank
0 Tenant Improvement 0 Other
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (founded to
the nearest dollar) of all equipment, materials, labor, overhead,
and the profit for the work Indicated on this application.
I/oluation:A 103
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement scl ft: Finished [I Unfinished 1:1
Ist Floor, scl ft:
2 nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT DESCRIPTION
0 ct'k�
I certify that the Information I have provided on this form/app 11 cation Is true,
correct and complete, and that I am the property owner or duly authorized
agent of the property owner to submlt a permit application to the CIty of
Edmonds,
Print Name:
Signature: Date2-17-10
V_ V
M'M
Im
0,
GENERAL COMMERCIAL DATA
Occupancy Group(5): occupant Load(s):
Type(5) of Construction:
Fire Sprinklers: Yes 13 No C3
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 City
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
ExhaustFans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
RoofTop Unit (Provide eleva-
tions If a Commercial Bldg)
Other:
PLUMBING FIXTURE COUNTS (New, Relocated or re -piped) N
City Cty
Clothes Washer
Tub/ Showers
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
DrInkIng Fountain
Pressure Reduction/ Regulator Valve
Floor Draln/Sink
Refrigerator Water Supply
Hose Bibs
Water Heater -Tankless? Y or@
HydronIc Heat
Water Service Line
Sinks
Other:
Tollets
other:
GAS/FUEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boller
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace Other:
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or re -piped)
QtY
City
Carbon Dioxide
Nitrous OxIdd
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 FPSCAA Case ft:
Critical Areas Determination:
Study Required 11 Con alver El
ditional W Waiver
Fill in Place 11 Fill Material:
Removal El Size of Tank (Gallons)
Critical Areas Determination:
Study Required 11 Conditional Waiver El Waiver 11
GRADE/FILL/EXCAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut/ Fill in Critical Area: Yes El No El
GENERAL PROVISIONS
APPLICATIONS: Appl(cations 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.