filename-1 (1)BUILDING PERMIT
APPLICATION Permit#:
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 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 call425-771-0220 to schedule an intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: i6o -- � -L4k ')Q_ %\.j
Parcel:
Lot /Unit/Suite #:
PROPERTY OWNER:
Name: AA01
Mailing Address:
City/State/Zip:
Subdivision:
Phone #:
Email: ..�i nn, ; 2�- ,,/!1'c.�r", t4Ax 1 .C_.Z)I, %
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ 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:
Mailing Address:
City/State/Zip: Q Q=��' 1 "x.)"'Ja' C
Phone #:
E-mail:
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: .A
Mailing Address: Al f oori-
City/State/Zip:
Phone
E-mail:�n
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
RG7TGKC0CZ.cik.
TYPE OF
❑ Accessory Structure/
Detached Garage
Details -
❑ Addition
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
Re -Roof
❑ Signs
❑ Tank
❑ 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,
y and the profit for the work indicated on this application.
Valuation: `��
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT DESCRIPTION
i
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.
PrintName:
Signature: Date��