18300 Andover 2 Application Form A.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
4, 1h
St. 1 9() 1215 Avenue N, Edmonds, WA 98020
5' . 19
City of Edmonds Phone 425.771.0220 J1 Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBM17-TAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): 0 M WO 5
Parcel #:
IV,3oo AmPatf-12. 5-r 'i
i- 76)q /6 4V / 0 C, 3 494)
Subdivision/Lot #:
Project Valuation: $
5FA&F- �A5C,4--*
APPLICANT:
-SHO
Phone:
Fax:
1
Address (Street, City, State, Zip):
E-Mail Address: -
i 3400 4/V,0VVr,& S—, e�MVMJI( WA
'rilt'04
5 K e-.1 14 0,m54- reA,
PROPERTY OWNER:
:�
Phone:
Fax:
I
Address (Street, City, State, Zip):
E-Mail Adpress:
( F, )
o;c, r-e
LENDING AGENCY:
Phone:
Fax:
Address (Street, City, State, Zip):
Lpo I VAllow <'f. -14-11300
E-Mail Address:
M z tt c\,e s4'rte+' to/, -
CONTRACTOR:*
Phone:
Fax:
I-ew's C0"VS—JAV1'T10'-1 eq'vp t-L-C
V �' 4,9 3 0 - 9 1 ?_ 7-
IM3
Address (Street, City, State, Zip):
E-Mail Address:
PO Rox 24 V) r 3 i.- vvt cz ej v 2- o
ZCA,- & i e w 4
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to
1-Cw I S C 6t 9'4'� % 57
doing work in the City. Contact the City Clerk's Office at 425.775.2525
City Business License #/Exp. Date:
9 L - 0 11415 / W-30hai
DETAIL THE SCOPE OF WORK: f4c,YT
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A 4-C $),v/) A,-39 2,V-O r"vA,,
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1v C_ (,v C)F-Fit-C 3/1-y 13A-7-H 13 f:A
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- — 6- PROPOSED NEW SQUARE FOOTAGE
FOR THIS PROJECT:
Basement: )y7 '4 sq. ft.
Select Basement Type: Finished LJ nfinished LJ
1 " Floor: 13,5" YEW —sq. ft.
Garage/Carport: 3 V AIC W —sq. ft.
2 d Floor: sq. ft.
Deck/Cvrd Porch/Patio: sq. ft.
Bedrooms #_I, Full-3/4 Bath # I- Half -Bath
Other: sq. ft.
Fire Sprinklers: Yes
E] No
0
Retaining Wall: es L] No LJ
-
Grading: Cut 7-5- cu. yds. Fill -cu.yds.
Cut/Fill in Critical Area: Yes LJ No LJ
I declare underpenah)? ofperjury laws that the information I haveprovided on thisformlapplication 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: LV ACA41,MS
Owner Agent/Other E] (specify):
Signature:
Date:
t C., /�11
FORM A LABuilding New Folder 201000NE & x-ferred to L-Building-New driveTomi A2014.docx Updated: 1/17/2014
0
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION FORM A
121 5h Avenue N, Edmonds, WA 98020
City of Edmonds
Phone 425.771.0220:k Fax 425.771.0221
Equipment Type
Appliance/Equipment Information (new and relocated) Total #
Furnace
Gas #—Elec #—Other:—
# BTUs: <100k_ >100k_ Location(s)
Air Handler / VAV
Gas #—Elec #_Other:—
# CFM: <10k. >10k_ Location(s)
(circle selected)
AC / Compressor
Boiler I Heat Pump
Gas #—Elec #—Other:_
k_ BTUs: <100k, _100k-500k, ____-500k-1Mjl
Roof Top Unit
HP: <3,
15-30 Location(s)
(circle selected)
Hydronic Heating
Gas #_Elec #_In -Floor
—Wall Radiant- Boiler BTUs:_ Location
Exhaust Fans (single
Bath 4L #—Laundry # —Other:
duct)
—IKiteben
Fireplace
Gas #—Elec #�__Other:—
# Location(s)
Dryer Duct
FUEL GAS
Appliance Type Appliance/Equipment Information (new and relocated)
Total #
A C Unit
BTUs:
Location(s):-
Furnace
BTU[s:
Location(s):-
Water Heater
BTUs: :r 3(o ,
aw Location(s): joiJ?— t:2 tA0.Q.'&'
Boiler
BTUs:
Location(s):-
Other:
BTUs:
Location(s):-
Fireplace/Insert
BTUs:
Location(s):-
Stove/Range/Ovcn
Dryer
Outdoor BBQ
TOTAL OUTLETS
PLUMBING
FIXTURE COUNT
Fixture Type (new and relocated)
Total # Fixture Type (new and relocated)
Total #
Water Closet (Toilet)
Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)
Water Service Line
Tub/Shower
Drinking Fountain
Dishwasher
Clothes Washer
Hose Bib
Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
Water Heater Tankless? Yes 0 No
Hydronic Heat in: Floor Wall
Floor Drain/Floor Sink
Other:
Refrigerator water supply (for water/ice dispenser)
Other:
FORM A LABuilding New Folder 2010\DONE & x-ferred to L-Building-New driveTorm A2014.doex Updated: 1/17/2014