Revised Application Page 1 (2)BUILDING PERMIT
APPLICATION
Development Services
Build
121 Sth Ave N / Edmonds'nWAivision 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswa aov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildingpermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 2LLuu q_E��os\� I
Parcel:
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name:
Mailing Address: 2.CJLj 1 Cl 'R1l4- ave (A)_
City/State/Zip: ErkT nlcl s (,AA gwcgo
Phone #: fn - 3 0
Email: C rY) V GC4 ► 7 K1%ln 1. rv1 r`r•r..-.
OWNER INSTALLATION: *if yes, read and sign"
Will work be performed by the property owner? ®yes ❑ No
I own, reside in, or will reside in the completed structure. This
installation is being made on property t t I own which is not
intended for sale, lease, rent, o ere according to RCW
18,27,090, /
Owner Signature:
1PPLICANT / CONTACT[�IN�F,,ORMA1TI^ON: r '
Name of Applicant:
�n_ X,� Cn'Y \ Cle I� , l
Mailing Address: �LA I 1 � fl' =V a=\& gWy�c� /
City/State/Zip: : (A ICitS u%1 1 gUV011d
E-mail
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:_
City/State/Zip:
Phone #:
E-mail:
STATE UBI M
CITY OF EDMONDS BUSINESS LICENSE #:
TYPE OF PERMIT (Provide Details
❑Accessory Structure/
❑Addition
Detached Garage
Demolition
Mechanical
New Single Family/Duplex
® Plumbing
Fire Sprinkler
®ERemodelNew
Commercial/Mixed UseEl
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:
�i
•••• • • ••
••APPLICATION
Basement sq ft: Finished ❑ Unfinished❑
1st Floor, sq ft:
2nd Floor, sgft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms:
# of NEW Bathrooms:
PROJECT•
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1 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. _
WA STATE CONTRACTOR L & I #: {CCB} & EXPIRATION DATE: I ' print Name:
Signature: