Maple Way Roof Permit Applicationf nC. 18y"
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 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: �Jrly YY1a1J� lc��I
Parcel: 00 i[-3L{-oZo(o g014Pad
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: D0.1f_ V6hn aj
Mailing Address: PO {boy. 7a
City/State/Zip: E� rr .js l.. Pt 90 ab
J
Phone #: � S�� % -% 9- ro74-9
Email:
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? '❑ Yes LAo
I own, reside in, or will reside in the completed structure. This
installation is being made on property that 1 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: 1ce� vNc-e—
Mailing Address:
City/State/Zip: Z m o h A s WA `i 9 C, a'd
Phone #: �kaS- 7 7 �?- io7q-'Q
E-mail: to�� {o a , G✓\ ce_ Cv�na•1 , c. o►h
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: Roafr,n4
Mailing Address: QU Go* -ab
City/State/Zip: e A c„n c s i uj A R a O
Phone #: �kA S - -7 -7 1-1.ti- of 9
E-mail: r b C Irn4A, c owl
STATE U B I #: (o 0 a 1 9 3 'j 9 9
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CfB) & EXPIRATION DATE:
00 Na yy,,
Office Use Only
TYPE OF PERMIT (Provide
❑ Accessory Structure/
Detached Garage
Details on Page 2)
❑ Addition
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
"ee-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,
and the profit for the work indicated on this application.
Valuation: $ "1 `i oa
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sgft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT•
Ice "fy that the information I have provided on this form/application is true,
corre t and mplete, and hat I am the property owner or duly authorized
agent the roperty ner to submit a permit application to the City of
Edmon
Print �� ��a�ievtcQ-
Sig ure: Date 411JIAO