2122_001J�A
ft�Xo BUILDING PERMIT
Mr r Lll%�#M I I %J
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020 TYPE OF PERMIT (Provide Details on Page 2)
425.771.0220
'J7 C. I S 9 '"
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edmondswa.pov.
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 call 425-771-0220 to schedule an Intake appointmentl
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 0Z 7 21-1A 2— U I St I A
Parcel: 6og 5 000000 70a
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: -612 C, k KAVJorl
Mailing Address: 0172,0 Z-Lllf+� SW
City/State/Zip:
Phone #: Zo
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:
Mailing Address:
City/State/Zip:
Phone #: �Ao 5 0� 0
E-mail: WX OA S P JftS:6A (JAW�kP a:�J, UW
GENERAL CONTRACTOR: (if different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI #:
0",
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATIOV DATE:
f AS_� WW 9 S C, I 9Qa;)-
Accessory Structure/
Detached Garage
0 Addition
0 Demolition
0 Mechanical
0 New Single Family / Duplex
* lumbing
• Fire Sprinkler
11 Remodel
• New Commercial/ Mixed Use
0 Re -Roof
0 Signs
El Tank
El Other
0 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 for the work indicated on this application.
Valuation: _1C 1?17
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished 0 Unfinished 0
1st Floor, sq ft:
2 nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT DESCRIPTION
(ko +W �A! a46y-
I certify that the information I have provided on this form/application Is true,
cnrrect 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
V__
a
GENERAL COMMERCIAL DATA
Occupancy Group(s): 70ccup.nt Load(s):
Type(s) of Construction: I FIre Sprinklers: Yes El 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
Boller
Dryer Duct
Exhaust Fans
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)
City City
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
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:
Furnac
Other:
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or re -piped)
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 CAA Case #:
Critical Areas Determination:
Study Required 11 Conditional Waiver Waiver
Fill in Place El Fill Material:
Removal
Size of Tank (Gallons)
Critical Areas Determination:
Study Required El Conditional Waiver El Waiver 0
G RADE/FILL/ EXCAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes E3 No 0
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.