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BUILDING PERMIT
oqq 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 NO 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 call425-771-0220 to schedule an Intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address:
Parcel: --()(10 I U%Ub1 O0 7�) r'
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: 6ar1dCVq l,e'N �
Mailing Address: _ Z �% by I DI n CA (�
City/State/Zip: ,rVil�Y�lll � ��/ gZ2UO
Phone #: —1z"E�7 ^
Email:
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ YesXNo
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: 11�1J� 1�a"fVt
Mailing Address: �jf pzy= mu )
City/State/Zip:l�Q��
Phone #: 5
E-mail: M S
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail: T
STATE UBI #: 0 J 15kAq
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Office Use Only
TYPE OF PERMIT (Provide
❑ Accessory Structure/
Detached Garage
Details on Page 2)
❑Addition
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
❑ Re -Roof
❑ Signs
❑ Tank
❑Tenant Improvement
❑ Other
j 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:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Easement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
end Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
C
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: `^^'^ sv— maon�"
Signature: Date —Lill Z 1�
®r
COMMERCIALGENERAL
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes ❑ 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
EQUIPMENTMECHANICAL • 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)
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? Y o(�)
Hydronic Heat Water Service Line
Sinks Other:
Toilets Other:
BTUs Qty BTUs Qty
A/C Unit Outdoor BBQ/ Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert Other:
Furnace I I I Other:
Qty City
Carbon Dioxide Nitrous Oxide
Helium Oxygen
Medical Air Other:
Medical - Surgical Vacuum Other:
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 ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material:
Removal ❑ Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
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.