20200428103626_001,I)C. I S91
BUILDING PERMIT Office Use Only
APPLICATION
eve opment eivices
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.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 appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: ;� 13�,q q5*,,k1e. W avlwmLs
Parcel: 00 ) / oocn!5�'!�-ev
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: -7�'M s ;Ta��
Mailing Address: �;arne a 5 a,�yyr_
City/State/Zip:
Phone#:
E m a i 1: io ik!� sl< i -f rn vel 6� rrV4 df-M
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? El Yes �� /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 IRCW
18.27.090,
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
GENERAL CONTRACTOR: (if different from applicant)
General Contractor:&w)qr� I&G-1v Ma -
Mailing Address: Is-"'AJ16- -5e ilk-101A
City/State/Zip: :?O�ell, W'4
Phone#:
E-mail:
STATE U B I #:
CITY OF EDMONDS BUSINESS LICENSE#:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
(_0r<A)M.T 0 &.("'m 5/7 / 20 Z 7-
TYPE Of PERMIT (Provide Details on Page 2)
El Accessory Structure/ 0 Addition
Detached Garage
Ll Demolition
El Mechanical
El New Single Family / Duplex
0 Plumbing
El Fire Sprinkler
0 Remodel
• New Commercial/ Mixed Use
Re -Roof
• Signs
El Tank
El Tenant Improvement
0 Other
Remodel Permit fees are based on:
I he value of the work performed. I riclicate the value (rounded to
the nearest dollar) of all ecluipment, materials, labor, overhead,
and the profit for the work indicated on this application.
Valuation:
Basement sq ft: Finished El Unfinished El
1st Floor, sq ft:
2nd Floor, scift:
Garage/Carport:, sq ft:
I
Deck/Covered Porch/Patio:
Other sq ft:
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.
PrintName:
Signature,50� Date 20
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 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)
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? Y or N
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
GAS/FUIEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BTU s 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 Survey done? Y/N
PSCAA Case #:
Critical Areas Determination:
Study Required El Conclitiona Waiver El Waiver 0
ii6ii6 I ii"Ii
Fill in Place Fill Material:
Removal
(Gallons)
Critical Areas Determination:
Study Required El Conditional Waiver El Waiver 0
GRADE/FILL/EXCAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes 0 No
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.
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City of Edmonds
Development Services
1215 1h Ave N, Edmonds, WA 98020
Phone: 425-771-0220
www.edmondswa.gov
Due to COVID-19 concerns, the Governor issued a Stay Home —Stay Health
Proclamation (20-25) on March 23, 2020. It went into effect March 26 and
has since been extended through May 4, 2020. Among other things, the
Proclamation (aka "Order") limits construction activities to only those that
support essential critical infrastructure or are otherwise exempt. Notably,
most residential construction is not allowed under the Proclamation.
However, a Construction Guidance memo from the Governor's Office provides
more details, especially for construction related to public entities and "to prevent
spoliation and avoid damage or unsafe conditions, and address emergency
repairs at both non -essential businesses and residential structures." The
City recognizes that many active construction projects are underway in
Edmonds and that some reasonable measures are anticipated and allowed
within the Order. All construction activity must meet social distancing and
appropriate health and worker protection measures before proceeding.
City staff does not perform inspections of construction projects unless the
inspection is for an activity that appears allowable under the Governor's order.
Homeowners and contractors are responsible for arranging inspections,
including completing this form that helps identify whether the inspection would
be for an allowable activity. Regardless, City inspectors have discretion as to
whether the inspection request is reasonable and can be safely performed.
To request a Building or Engineering inspection, complete this form, print
and/or save it and then email it to: devserv.admin@edmondswa.gov.
Note: if needed, the City may request additional information.
indicate Exemption Category:
9 Construction related to essential activities as describe in the Governor's
I A; t; I ; f tr"rt"ro mrtivAtioc
Inspection Procedures under
the COVID-19 Emergency
• Requests for construction
inspections will be accepted and
scheduled by the City only for
activities that appear to be within
an exempt category, per the
Governor's Order.
• No inspections shall be requested
for work that is inside an
occupied building in which
occupants are displaying
symptoms of illness, are currently
sick, or have been sick within the
past 14 days.
• In -person inspections in occupied
heated spaces are generally
suspended. Inspections for life
safety issues in an occupied
heated space will be evaluated
on a case -by -case basis.
• Inspection sites are subject to
social distancing and all
appropriate safety/health
precautions.
• Inspections may be canceled or
postponed at the inspector's
discretion.
Order ' inc u "g, ease" a " , as
D To further a public purpose related to a public entity or a governmental
function or facility (including but not limited to publicly financed low-income housing).
El To prevent spoliation and avoid damage or unsafe conditions, or to address emergency or life -safety construction
activities, such as residential furnace/water heater repa ir/re placement or water and sewer service line repairs.
Provide Project Intormation Below. (Nore:LompierionO.Tl4LLfieIU5i5refr4utitfu.I
Permit Number: I Requested inspection Date: 5/4 & 5/11/2020 DAM @9 PM
Site Address: 21329 95th Avenue West, Edmonds, WA 98020
Inspection Type(s):TEAR OFF inspection 5/4/2020 and FINAL inspection 5/11/2020
Contact Name: Craig Miser I Contact Telephone: 206-786-5241
Contact Email: kristy@cornerstoneroofing.com
Describe how each requested inspection fits with one of the three exemption categories above. (Required)
This homeowner has 3 holes in his roof and a re -roof is required. We have our Covid19 safety plan
at all jobsites.
04/09/2020