1718_001NIA
.. °" ""'oti SI�� BUILDING PERMIT
° 1 APPLICATION Permit #:
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020 TYPE OF PERMIT (Provide Details on Page 2)
-1c. I S9 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 call415-771-0110 to schedule an Intake appointmentl
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address:? .101 73ed An W.
Parcel: OO47/S000VV
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: Gleeno- ( vino
Mailing Address:C,111311 %.3rd M. W,
City/State/Zip: ynd f , w,4 um
Phone #: W5-- 3T-1 ^9430
Email:
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ YesxNo
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: �GIS� 1 M(X -i&; f/r
Mailing Address: I1(115 0 (Atfkj(= Ku)�S_oI
City/State/Zip:: 11)�Au' 'ZI I1 , w fl t i ov"
Phone # `-A -A ( S'0"J\D '+t)'Tui
E-mail: fV1 1 •fi s -1:tQ-M)LL`1W UL
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI #: 05 vl�
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: CCB) & EXPIRATION DATE:
'SAS-TW�u "�1AZB C I - \-i-90;�
❑ Accessory Structure/ J
Detached Garage
❑ Addition
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ Re -Roof
❑ New Commercial/ Mixed Use
❑ Signs
❑ Tank
❑ Other
❑ Tenant Improvement
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 forthework indicated on this application.
Valuation: 571
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Easement sq ft: Finished ❑ Unfinished ❑
Ist Floor, sq ft:
2 nd Floor, sq ft:
Garage/Carport;, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECTDESCRIPTION
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,
MOR
Print Name:"
Z
Signature: Date
COMMERCIALGENERAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction:
Fire Sprinklers: Yes ❑ 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
EQUIPMENTMECHANICAL •
BTUs Gas / Elec / Other City
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other
PLUMBING FIXTURE • ..
City 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 oro
1
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
CONNECTION COUNTSRelocated or .. .
BTUs City BTUs City
A/C Unit
Outdoor BBQ / Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
Other:
COUNTS'.MEDICAL GAS,.AIR VACUUM
Relocated .
Qty City
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:
AHERA Survey done? Y / N JPSCAA Case #:
Critical Areas Determination:
i'uoyRequired ❑ Conditional Waiver ❑ Waiver ❑
Fill In Place ❑ Fill Material:
Removal ❑ Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
GRADE�FILL/EX'CAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ 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.