FIR2020-0079_City_Application_9.2.2020_3.50.12_PMpc 1 0v
BUILDING 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 coil425-771-0220 to schedule an intake appointment!
JOB SITE INFORMATION/LOC�hyATION: (Where the work is taking place)
Job Site Address:-1Zp1-m ST SW e c�r�rlandJ
Parcel: �I_Ahhn t\�#Tbo
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: NVC�AYVI�Y—Y1C��` StWl\\ht
Mailing Address: ,12 3pi ST S•Y�l
City/State/Zip: -P'6MW)C 1S . \N o WUV
Phone #: 4715 AT (, 0 2APD
Email: �,`no►hairaC,ln-1�4o1�C �1o�hoo• t�1nr�
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ 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 RCW
18.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION: �
Name of Applicant:-CW\,hS -A 'DONWO
Mailing Address: N%
City/State/Zip: \Ayv1
Phone #: Q11Uki'Yo Is-"ryry 1 ' \
E-mail:NAY)m b"A t k �fAYl`�hP 7I U��l'W• r`Q�
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:p-
STATE UBI #: _A r
CITY OF EDMONDS BUSINESS LICENSE #: %OU - "1
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
k14%5dd* 0o\K�- 1`4 lUV
Office Use Only
TYPE OF Details on Page
❑ Accessory Structure/
❑ Addition
Detached Garage
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
❑ Re -Roof
❑ Signs
❑ Tank
❑ Other
❑ Tenant Improvement
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (rounded to
'he 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
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•
tl - n ..- ItA
10i"0
fA • "ILI f �U
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: (_ ^ *'Dakkoo 11�1gAIG'1�
Signature: Date ►�.j w�^'
.Oc.cupancyGrdup(s)- :Occupant1oad(s):
Type(s) of Construction:. Fire Sprinklers: Yes 0 No 0
WA STATE ENERGYCODEt If your project affects the buildingenvelope;
mechanical.systerns, and/or lighting, you Must. complete the.
appropriate. WSEC forms.
DEFERRED SUBMITTALS: All commercial building permits that Will* r6quire
associated plumbing* mechanical, fire tpAhkfeej and/or flee aflarm
permits are applied4or separately,
T11 CHANGE. bF.VSE / NEW BLDG:-.Iric*l*ud*e TRAFFIC IMPACT. worksheet
MECHANICAL EQUIP ENT*COUNTS- (New -and.' . 11'elocated . I
M
BTUs GasjElec./ Other Qty
A/C. Unit /Compressor
Air Handler./VAV
Roildr
Dryer Duct
Exhaust Fans.
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit* (Provide - el eiva-
tions Jfa=Commercial Bldg).
Other:.
PLUMBING FIXTURE COUNTS (New, Relocatedicir re-pip,ed)
.QtY Qty
Clothes Washer
Tub/ Showers
..Dishwasher.
Backilow Device (IRPBA, DCDA, AVO
Drinking fountain
Pressure.Reduction[Regulator Valve
.Floor Drain/Sink
Refrigerator Water . Supply
Hose Bibs
Water Heater - Tankle*ss? Y or.N
.Hydronic Hiaat*
Water Service Line
Sinks
bther*.
Toilets
Other:
GAS/FUEL CONNECTION COUNTS NTS (New; Relocated or - r'
.e pioed)
BTUIS Qty BTUs Qty
A/C* Unit
Outddor.BBQ/Fire pit It
Boiler
Stove/Range/Oven.
Dryer
Water Heater
Fireplace/ insert
Other..
Furnace*. Other:
MED I CAL GAS, AIR VACU U M'COU NTS
Reloeat'ed opiped)
Qtv otv I
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum
Other:
Type bfstruct6re to. be. demolished:
Sclua re footage of struc.ture.to be
AHERA Survey done? Y/N -PSCAA Ca.s4,#;
Critical Areas D6terrni nation:
Study Required 0 Conditional Walver 0 * Waiver 0
Fill in.. lace FilWatirial: V't vt
Removal 11 Size.of Tank *(GaIIons.:)*10b0k41
Critical Areas.Detetmination:
Study Required *0 Conditional Waiver 0 Waiver'❑0
GRADIE/FILL/EXCAVATE
Grading -..Cut cubic yards
Fill cubic yards
tu*t Fill in Critical Area; 'Yes 0 * No 0-
GENERAL PROVISIONS
APPLICATIONS. Applicationsarevalid lbr-*a maximum of I.year..
ESLHA Applications, 2- years.
LICENSING: -All *contractors.*and subcontractors are required to be licensed
with Washin n State Department of Labor& Industries in e Washington .0hav a..
current City of Edmonds Business License.