4216_0011'0-h- 1�r
0%- f-'T)N0 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: I)ttp.://www.ecimoiidswa.gov/
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
JobSiteAddress: 'jLfi%(W S I V. —\-I L.A:)
Parcel:
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: 'Seteck- [Vic.
MailingAddress: r3V-'%- ki-c-W
City/State/Zip: (W1\nVXWo.0a u)a CIT03-+
Phone#: qZS.-t(q7'-('90qq
Email: C-Ov"
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? Dyes []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: . K�Mko' NzCkAAS, %&C� RowV-S'll,
MailingAddress: JUSS1 IV-RV<-W- �,�_C-440-+
City/State/Zip: 1�4%n-xk,104 LUA- cK03-+
Phone #: qz.; - 7qz, &o gif
E-mail: e- (A &j U - C I &A— 12 0 U" 0 0 ( A
GENERAL CONTRACTOR: (if different from appricant)
General Contractor: Sele
MailingAddress: AVQ_- W - '�+CAO+
City/State/Zip: i_v1AW0'jLi' Wiq 119,03-t-
Phone #: Z4 K - 911-41 Z - (0 0 V41
E-mail: k & , - I &_, C U 'JAi 0 0 V_ - CWj --I
U
WA STATE CONTRACTOR L & I # (CCB) & EXPIRATION DATE:
CITY OF EDMONDS BUSINESS LICENSE M KYZ - 02 LeS9 I
3-LYS
7 Permit #:
72- 0 1 '57 - I ) -7 (,�7
TYPE OF PERMIT (Provide
0 Accessory Structure/
Detached Garage
Details on Page 2)
El Addition
El Demolition
C@*,New Single Family / Duplex
11 Mechanical
0 Plumbing
El Fire Sprinkler
El Remodel
El Re -Roof
11 Tank
0 Other
0 New Commercial/ Mixed Use
El Signs
El Tenant Improvement
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (rounded to
the nearest dollar) of all equipment, matedals, labor, overhead,
and the profit for the work indicated on this application.
Valuation:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished 0 Unfinished El
Ist Floor, sq ft:
lqzs
2nd Floor, sq ft:
1 ?1, 0
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
r-Other sq ft:
PROJECT DESCRIPTION
1'� f-W S 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 ofthe property owner to submit a permit application to the City of
Edmonds.
Print Name: A%A Ls
Signature: Date
GENERAL COMMERCIAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: 3V,�L Fire sprinklers: Yes K 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)
Other:
PLUMBING FIXTURE COUNTS (New, Relocated or re -piped)
QtY 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?&orN
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
GAS/FUEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs Qty BTUs 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 Conditional Waiver El Waiver El
Fill in Place El Fill Material:
Removal E]
I Size of Tank (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 EJ Nok
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.