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7622 Roberson Edmonds Permit Appfne. 1?'9 BUILDING PERMIT APPLICATION Permit#: Development Services Building Division 121 5th Ave N [ Edmonds, WA 78020 425.771.0220 For handouts, submittal requirements, permit status and inspection scheduling information go to: www_edmandswa.gov_ 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 eiectronic files on a flash drive or coordinate for electronic transfer. Please call425-771-0220 to schedule an intake appointment! JOB SITE INFORMATION/LOCATION: (Where the work is taking place) .fob Site Address: _ 7& ZZ jl5-t4"' 5+ 5 0 Parcel: Z-70 g 0-7nd 4 0 V J 00 Lot /Unit/Suite #: Subdivision: PROPERTY OWNER: Name: 66Wytc`. TAP.t 500 Mailing Address: 7?6ZZ 12 5 +1' S -� 5 1,> City/State/Zip: e J wk_pvtc�S� WA- !3 90 Z .b_ Phone #: 2042,T ` 23- YL16 0 Email: met; I 1. S �&Lt.v & & 'itA4r. i � . C . wl OWNER INSTALLATION: *If yes, read and sign* Will work be performed by the property owner? ❑ Yes jfNo 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: I—Aex- 60" Mailing Address: � �i Z�_ t% 6+ S LO City/State/Zip: Ec s6&� &d A I ocOZ 6 fir Phone#: Z06- ZS 3- `N'60 E-mail: Inn"L 1 1 5 kA A 011 ►Mof r snI GENERAL CONTRACTOR: (If different from applicant) General Contractor: Ctq,g onp Cvt+ #u4vv&Apk Mailing Address: 2 0 7,� 7 1yl o ;,� V t e u R City/State/zip: 0 1Ayr,,t1 ? t).A 119019 — l3 Phone #: 2 O & - q51 -- 6 ZZS E-mail: Ck'4VMCLL+ r'evlAOGt?\ e A V1'0"' ` . C-w` STATE UBI #: 603 -- II'L V'K3 CITY OF EDMONDS BUSINESS LICENSE #: 603 - I I `f - 1-1,93 WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE: �5'S 367 - oz 3-P/- Zoz! TYPE OF PERMIT (Provide Details ❑ Accessory Structure/ C] Addition Detached Garage ❑ Demolition ❑ Mechanical ❑ New Single Family / Duplex ❑ Plumbing ❑ Fire Sprinkler ❑ Remodel ❑ New Commercial/ Mixed Use ❑ Re -Roof ❑ Signs © Tank Tenant Improvement ❑ Other Remodel Permit fees are based on: The value of the work perf,ormed_ 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: 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: Other sq ft: PROJECT DESCRIPTION l K4� PW e1041, OWL" �t V�nc tirdovh. G.�of ne01c, LL t.?11 It �e re V.L�rlvl by u0'irIzdl'y �s? -EroutE ;Zarck SAS 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. C I— Print Name: J '`��V�GL p�E $D✓1 Signature: Date r I i c-r rl r St RG 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 WSECforms. 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 • BTUs Gas / Elec / Other Qty A/C Unit /Compressor Air Handler/VAV Boiler Dryer Duct Exhaust Fans��+r 3 Fireplace 56 K GAS [ Furnace Heat Pump Unit Hydronic Heating Roof Top Unit (Provide eleva- tions if a Commercial Bldg Other: COU NTS (New, Relocated or re -pi ped) Qty Qty Clothes Washer Tub/ Showers Z 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 (4 Other: Toilets Other: CONNECTION COUNTS.. .. BTUs Qty BTUs Qty A/C Unit Outdoor BBQ / Fire pit Boiler Stove/Range/Oven Dryer Water Heater Fireplace/ Insert j6 Other: Furnace Other: COUNTSMEDICAL GAS, AIR VACUUM (New, Relocated or re -piped) Qty Qty Carbon Dioxide Nitrous Oxide Helium Oxygen f Medical Air Other: Medical --Surgical Vacuum I Other: DEMOLITION Type of structure to be demolished: Square footage of structure to be demolished: AHERA Survey done? Y / N PSCAA Case n: Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑ PM Fill in Place ❑ Fill Material: Removal ❑ Size of Tank (Gallons) Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑ GRADE/ Grading: Cut cubic yards Fill cubic yards Cut / Fill in Critical Area: Yes ❑ No ❑ GENERAL•• • 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.