application"V. 10,
BUILDING PERMIT
APPLICATION 7PIrmit#:
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswo.aov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildinatiermit.com,
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: sire 4S
Parcel: 005 1 3 i 0000 H(oQ S
Lot /Unit/Suite #:0-1 Subdivision: AVA' Ou }
BUSINESS OR PROPERTY OWNER: I (� b`
Name: SrtZ-y � ( cf� L_rz,
Mailing Address: 160 3 O AVE, W.
City/State/ ip: END Mof xc)s V/4 O b
Phone #: '`L�3 V
Email: sh teUQ_A. 0ble59@/iAV1oy,co,,"
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner?R]YesF—]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:
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APPLICANT / CONTACT INFORMATION: {�
Name of Applicant: NO
Mailing Address: i o o b (J11-4AV E, cW ,
City/State/Zip: VoN W,
Phone #: 62-o(03 4_
E-mail: '1;'f' eVe_IAt.VL010IEe J I to, A&/ 0�C.o✓t'�
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:
(ProvideTYPE OF PERMIT
❑ Accessory Structure/
Detached Garage
Details
Addition
❑
Demolition
Mechanical
New Single Family/Duplex
Plumbing
Fire Sprinkler
® Remodel
New Commercial/Mixed Use
Re -Roof
Signs
❑ Tank
❑ Tenant Improvement
® Other L 4
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: I br 000 , 06
IT -
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sgft: Finished ❑ Unfinished❑
1st Floor, sq ft:
2nd Floor, sgft:
Garage/Carport:, sq ft:
170teci*/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
PROJECT
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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
j agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: v 'v 00 is
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Signature: - Date 1
1