THOMPSON APPLICJ�A
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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.aov.
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 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:: 7_Z1,y8 7Z ►\o( ,b 1 W
Parcel: o0•'1 "Lq /0(0bt)t..0D
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: Sit T1Vrftes' j i1
Mailing Address: Z Zsa 7 ZhAk M w
City/State/Zip: ELM-RfICC , WA g9tMp
Phone #: L96 -1,�07-(Q'7+-�
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: I� ,, `�
Name of Applicant: �UIJ� 11VV�'fV` (1�o-ity
Mailing Address: ��1� �AffkLY, WIA )_ S Ip�
City/State/Zip; �f QA l , WA gmoDll
Phone # 5
E-mail: 6A IA S
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail: "
STATE UBI #: Q Oa-���
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATIO DATE:
,WL)T VJW q U19 8 C I - 90 ;)-
Office Use Only
OF
I TYPE J
❑ Accessory Structure/
Detached Garage
Details ..-
❑ Addition
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ Re -Roof
❑ New Commercial/ Mixed Use
❑ Signs
❑ Tenant Improvement
❑ Tank
❑ 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,
I and the profit for the work indicated on this application.
Valuation: 13q -7
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Easement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sgft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT•
.�,►)� _ V.Y. V�,Tc/�
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 Name:
Signature: Date 0�1-15�Z�i
WE
F�
GENERAL •
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 Qty
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:
COUNTSPLUMBING 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-Tanklecs? Y or 1 `
Hydronic Heat Water Service Line �J
Sinks Other:
Toilets Other:
CONNECTION COUNTS
BTUs Qty BTUs Qty
A/C Unit Outdoor BBQ/ Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert Other:
Furnace Other:
MEDICAL•
Relocated or re -piped)
Qty Qty
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 PSCAA Case #:
Critical Areas Determination:
iM
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material:
Removal ❑ Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
GRADE/FILL/EXCAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
GENERAL•• •
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.