BLD2020-0995+City_Application+9.25.2020_11.44.17_AM``? C. 189.,
BUILDING PERMIT Only
APPLICATION Perrrur:
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www..edmondswa_go..v.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildinapermit.com,
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 22214 HWY 99
Parcel: 201809205002
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: Doug's Lynnwood Mazda
Mailing Address: 22130 HWY 99
City/State/Zip: Edmonds, WA 98026
Phone #: 4257743551
Email: mikegami@dougs.com
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 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: Marc lkegami
Mailing Address: 22214 HWY 99
city/state/zip: Edmonds WA 98026
Phone #: 2069924942
E-mail: mikegami@dougs.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: Wilcox Construction
Mailing Address: 234 5th Ave S
City/State/Zip: Edmonds, Wa 98020
Phone #: 425-774-4185
E-mail.. Mmcisaac@wilcoxconstruction.com
STATE UBI #: 319-007-592
CITY OF EDMONDS BUSINESS LICENSE #: BL-006453
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
CC WILCOC*19400 12/10/2021
TYPE OF PERMIT (Provide
Details on ..-
✓
Accessory Structure/
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 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: 15,000
PROPOSED NEW SQUARE
Basement sq ft:
FOOTAGE FOR THIS APPLICATION
Finished Unfinished
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
800
Deck/Covered Porch/Patio:
# of NEW Bedrooms:
PROJECTDESCRIPTION
CUI�Sa.ucTlt�r-1
# of NEW Bathrooms:
OF h1�T,AL j3V1t-D.i NV ',
�R WA541 '43P-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. r•
Print Name: T o0U&LA3�K�G'1►^'
1
Signature: ��� Date
COMMERCIALGENERAL DATA
Occupancy Group(s): S_ 1 Occupant Load(s): 4
Type(s) of Construction: rj-B
Fire Sprinklers: Yes ❑ NoR1
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 / Elec / Other Qty
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE d or re piped)
Qty Qty
Clothes Washer
Tub/ Showers
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
2
Water Heater - Tankless? Y or N
Hydronic Heat
Water Service Line
1
Sinks
Other:
Toilets
Other:
CONNECTION COUNTSd 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
Relocated or piped)
Qty
Qty
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum
Other:
DEMOLITION
Type of structure to be demolished:
Square footage of structure to be demolished:
AHERA Survey done? Y❑/ N❑
PSCAA Case q:
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
III
Fill in Place ❑ Fill Material:
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
GRADE/FILL/EXCAVATE
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.