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BUILDING PERMIT
APPLICATION Permit#:
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Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to:
To apply for permits, schedule inspections, or check application status
go to:
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 22408 97th Ave W
Parcel: 00559000100100
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: Christopher Gillette
Mailing Address:
22408 97th Ave W
City/State/Zip: Edmonds, Wa 98020
Phone #.. 2066017711
Email: chris.gillette@ymail.com
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner?❑Yes1V]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: Chris Gillette
APPLICANT / CONTACT INFORMATION:
Name of Applicant: Chris Gillette
Mailing Address: 22408 97th Ave W
City/state/zip: Edmonds, Wa 98020
Phone it: 206 601 7711
E-mail: chris.gillette@ymail.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: Dave Van Slyke
Mailing AddressP.O. BOX 170
City/State/Zip: Hansville, WA 98340
Phone #: 360 297 1774
E-mail: vanslykeconst.incCCgmail.com
STATE UBI M 601 787 923
CITY OF EDMONDS BUSINESS LICENSE #: <$12,000
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
VANSLC1034LB 5/12/2022
TYPE OF PERMIT (Provide
Accessory Structure/
Detached Garage
Details on Page 2)
Addition
Demolition
❑ Mechanical
New Single Family/Duplex
R1 Plumbing
Fire Sprinkler
RI Remodel
New Commercial/Mixed Use
Re -Roof
Signs
❑ Tank
Tenant Improvement
❑
Other
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: 10,000
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished❑ Unfinished❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
PROJECT DESCRIPTION
1FRUUMIS,
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 submit a permit application to the City of
Edmonds.
Print Name: Christopher Gillette
Signature: fv � : Date 10/21 /20
GENERAL• DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction:
Fire Sprinklers: Yes❑ No❑
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
EQUIPMENTMECHANICAL • . Relocated)
BTUs Gas / Eiec / Other Qty
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
Electric
2
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)
Qtv Qty
Clothes Washer
Tub/ Showers
1
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
2
Other:
Toilets
1
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:
COUNTSMEDICAL GAS, AIR VACUUM
(New, Relocated or re piped)
Qty
Qty
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum Other: Li
DEMOLITION
Type of structure to be demolished:
Square footage of structure to be demolished:
AHERA Survey done? YE]/ N❑
PSCAA Case #:
Critical Areas Determination:
Study Required❑ Conditional Waiver❑ Waiver❑
Fill in Place ❑ Fill Material:
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
•.•
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
GENERALPROVISIONS
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.