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ArPLICATIO
Development Services
Building Division
5th Ave N / Edmonds, WA 98020
425.771.0220
121
BUILDING PERMIT
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edinondswa.gov.
PLEASE NOTE., Intake appointments are required for New Single Family
Residences, Large Additions, ADU's, New Commercial, and Mojor 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 call 425-771-0220 to schedule an intake appointmenti
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
JobSiteAddress: madypofc /./,a.
Parcel: 0050q 70Q 100 MID
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: WIKKICA, Mwill
Mailing Address: [A b1l)
City/State/Zip: aCj�02QIOi %AJA ClabZ�
Phone #: Ll ZG — ha,17 A
Email: -
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? El 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:.'OSA \K)MV VA-WW
Mailing Address: tl LkrfRX_- OYW�S*
City/State/Zip: WA. 01 0V I I
Phone #: ON
E-mail: AA
GENERAL CONTRACTOR: (if different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI #: 0" 5
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
�ASTVJU) " qk�S 90 L I - U1 - 9-Da �
Office Use Only
I TYPE OF PERMIT (Provide
• Accessory Structure/
Detached Garage
Details on Page 2)
0 Addition
• Demolition
0 Mechanical
• New Single Family/ Duplex
KP lumbing
111 Fire Sprinkler
El Remodel
0 New Commercial/ Mixed Use
0 Re -Roof
0 Signs
0 Tank
0 Tenant Improvement
El 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: $1317
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICA 1 1014
Basement sq ft: Finished El Unfinished 0
Ist Floor, sq ft:
2 nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT DESCRIPTION
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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
zgent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: &MIA maiinfl�
Signature:d-fx 10-2;0
V� Date
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GENERAL COMMERCIAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes 11 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
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
BTUs Gas Elec Other Qty
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
ExhaustFans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
PLUMBING FIXTURE COUNTS (New, Relocated or re -piped)
Qty 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? Yo<N)
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
GAS/FUEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BTUs Qty
A/C Unit Outdoor BBQ/ Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert Other:
Furnace Other:
MEDICAL GAS, AIR VACUUM COUNTS
(New, 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 Surveyclone? Y/N PSCAA Case #:
Critical Areas Determination:
Study Required E Conditional Waiver El Waiver El
Fill in Place Fill Material:
Removal E] I Size of Tank (Gallons)
Critical Areas Determination:
Study Required El Conditional Waiver El Waiver El
G RADE/F ILL/ EXCAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut / Fid in Critical Area: Yes El No El
GENERAL PROVISIONS
APPLICATIONS: Applications are valid for a maximum of 1 year.
ESILHA 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.