Kevin Fox PermitBUILDING 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 theworkwork is taking place)
Job Site Address: l.;'P% /Hk ee �s�
Parcel:
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: ,,(�,E�/'v /W /�//
Mailing Address: � Sr z��r� e /�/
.-
City/State/Zip:ixoAo lmo 410e &1'71"
Phone #: 206 �6) ��5 3'_
Email: e�mm ,49 g.��/ 7 Ct t,
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ Yes & o
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: /716�1 1&401411141��
Mailing Address: A/ eey"' %7� ®/� 11,��
City/State/Zip!: G'iYOAl,�
Phone #:
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI #: 1� 7� e-- 7
CITY OF EDMONDS BUSINESS LICENSE #: ?Z
Office Use Only
TYPE OF Details ..-
❑ Accessory Structure/ ❑ Addition
Detached Garage
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
El New Commercial/ Mixed Use
,/❑Remodel
L6' Re -Roof
❑ Signs
❑ Tank
❑ Tenant Improvement
❑ Other
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (rounded to
j the nearest dollar) of all equipment, materials, labor, overhead, j
and the profit for the work indicated on this application.
i
Valuation:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT•
n�Y CfTG 4y1v1��y/V
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:��%����
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
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Signature: