BLD2020-0884_City_Application_8.20.2020_1.27.20_PM, h c I .,".,
BUILDING PERMIT
APPLICATION I Permit.:
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondsw9..kov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildino g!,CT t cam
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
lob Site Address: » OW 2
Parcel:
Lot /Unit/Suite #: 416 Subdivision:
BUSINESS OR PROPERTY OWNER:
Name:
Mailing Address: Sg�7���; (�ll��rr :( (,/e( ;V /tp
City/State/Zip:—��'(3:,-C:,j 1-3{����L4L2cA
Phone #: 2_o ( — 7_17q —,!� S!6 /
Email: 54 v1,14 4 S i,c f-wr.� I •
OWNER INSTALLATION: *If yes, read and sign'
Will work be performed by the property owner? ❑Yes [A 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:
Mailing Address:
City/State/Zip: _L_Y}zt _ <«j
r
Phone #: ¢ _ — 17�3
E-mail: -`-'l --e� ��/
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address: 4.24 �,��1� A
City/Star
Phone #
E-mail:
STATE U
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
5 flS.,L�: 9_/j s �M
TYPE OF . • Details on Page
Accessory Structure/ Addition
0
Detached Garage
Demolition
Mechanical
ElNew
Single Family/Duplex
Plumbing
Fire Sprinkler
Remodel
New Commercial/Mixed Use
Re -Roof
Signs
I ❑ Tank
Tenant Improvement
D Other
Remodel Permit fees are based on:
The vclue of the work performed. Inclicote the value (rounded to
the neorest dollar) of all equipment, moterials, labor, overhead,
and the profit for the worts indicated on this application.
Valuation: =A .? !�_oQ
a
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 subm;t a permit application to the City of
Edmonds. _
Print Name: ��G%ri�-s' rl Ad<_.
Signature: Date - Zy