4436_001BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
AI)C 771 n,3,)n
loc. 10V
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edrnondswa.fo .
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 I NFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 7429 N. Meadowdale Rd.
Parcel: 00513103000900
Lot/Unit/Suite#: 10
PROPERTY OWNER:
Subdivision: Meadowdale Beach
Name: Keith and Pam Ainsley
MailingAddress: 7429 N. Meadowdale Road
City/State/Zip: Edmonds, WA 98026
Phone #: 425-742-0884
Email: KeithA@PacificCrestConst.CoI11
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? IN Yes El 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, lea� ange according (to RCW
18.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: Keith Ains
Mailing Address: 7429 N. Meadowdale Rd.
City/State/Zip: Edmonds, WA 98026
Phone #: 425-742-0884
E-mail: KeithA@PacificCrestConst.com
GENERAL CONTRACTOR: (if different from applicant)
General Contractor:
Mailing Address:—
City/State/Zip:
Phone #:
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Oftice Use Only
Permit 0: 20�,' D - 032, 5
TYPE OF PERMIT (Provide
• Accessory Structure/
Detached Garage
Details on Page 2)
0 Addition
• Demolition
0 Mechanical
• New Single Family / Duplex
F1 Plumbing
El Fire Sprinkler
0 Remodel
0 New Commercial/ Mixed Use
0 Re -Roof
El Signs
1-1 Tank
El Tenant Improvement Other Deck
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: $5,000
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished El Unfinished El
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
64 sf
Othersqft:
PROJECT DESCRIPTION
4' x 16' addition to an existing deck.
I certify that the Information I have provided on this form/appllcation 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. k L—f 111—H Al A/5 j_ i:E7
Signature: Date 2C 1
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 H.andler. /VAV
Boller
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)
City 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? Y or N
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
GAS/FUEL CONNECTION COUNTS (New, Relocated or re -piped)
BTUs City BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boller
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnac
Other:
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or re -piped)
City City
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 0 Fill Material:
Removal El Size of Tank (Gallons)
Critical Areas Determination:
Study Required El Conditional Waiver El Waiver 0
GRAD E/FI LL/ EXCAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut/ Fill in Critical Area: Yes 0 No EJ
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.