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BUILDING PERMIT
yqoqN 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.edinondswa.gov,
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 call 425-771-0220 to schedule an intake oppointmenti
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
JobSiteAddress: 19cl-th lf± sw
Parcel: ZIOLf Ono 10 I(P-00
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
-wevur r)o
Name: _1:N-_ka12D
Mailing Address: _7ql(D 1qqA , (-L- _�A )
City/State/Zip: alM_12134 IXA- =Z(O
Phone #: 2-0 �_ :Z q1_ 2.C97
Email:
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? 11 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: vs& wmv VA-a-tt/r
Mailing Address: CID
City/State/Zip:
_LD�AuJ�, UA q&l,
Phone #: '-Vs �05�011L'-N
E-mail: rA . I � S P O'Au- Vu me'r lym
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
0/)
STATE UBI #: r
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
� WA-) UJ S -
�AS ?) C I V1 -
Office Use Only
TYPE OF PERMIT (Provide
Details on Page 2)
0 Accessory Structure/
Detached Garage
0 Addition
El Demolition
11 Mechanical
1:1 New Single Family / Duplex
Plumbing
0 Fire Sprinkler
E] Remodel
El Re -Roof
0 New Commercial/ Mixed Use
0 Signs
0 Tank
0 Tenant Improvement
11 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: 113YO
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Easement sq ft: Finished 0 Unfinished 11
Ist Floor, 5q ft:
2 nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
FC,th.r sq ft:
PROJECT DESCRIPTION
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_421
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111111119.91 a Ue '
I certify that the information I have provided on thls 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:
Signaiture: df/�A
U _=� Date
V_ _. - - - . 0
13 15-
P. i.=
GENERAL COMMERCIAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes El No El
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 City
A/C Unit /Compressor
Air Handler /VAV
Boller
Dryer Duct
ExhaustFans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg) I I
Other: I I
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? Y A)
Hydronic Heat Water Service Line
Sinks Other:
Toilets Other:
BTUs City BTUs Qty
A/C Unit Outdoor BBQ / Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
1 71 Fireplace/ Insert Other: I
Furnace I I I other:
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum
Other:
I Type of structure to be demolished:
Square footage of structure to be demolished:
AH ERA Survey done7 Y / N PSCAA Case #:
Critical Areas Determination:
Study Required D Conditional Waiver ID Waiver El
Fill in Place El Fill Material:
Removal 11 1 Size of Tank (Gallons)
Critical Areas Determination:
S I tudy Required 11 Conditional Waiver 0 Waiver El
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes El No 11
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.