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BLD2020-1071+City_Application+10.11.2020_3.30.04_PMBUILDING PERMIT APPLICATION Development Services Building Division 121 5th Ave N / Edmonds, WA 98020 425.771.0220 JOB SITE INFORMATION/LOCATION: (Where the work is taking place) Job Site Address: ______________________________________ Parcel: ______________________________________________ Lot /Unit/Suite #: _________ Subdivision: __________________ BUSINESS OR PROPERTY OWNER: Name: ______________________________________________ Mailing Address: ______________________________________ City/State/Zip: ________________________________________ Phone #: _____________________________________________ Email: _______________________________________________ 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: ____________________________________ Mailing Address: ______________________________________ City/State/Zip: ________________________________________ Phone #: _____________________________________________ E-mail: ______________________________________________ GENERAL CONTRACTOR: (If different from applicant) General Contractor: ____________________________________ Mailing Address: _______________________________________ City/State/Zip: ________________________________________ Phone #: _____________________________________________ E-mail: ______________________________________________ STATE UBI #: _________________________________________ CITY OF EDMONDS BUSINESS LICENSE #: __________________ WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE: ____________________________________________________ Office Use Only Permit #: TYPE OF PERMIT (Provide Details on Page 2) Addition Wlumbing Remodel Ze-Roof Tank Other ________ͺ____ 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: __________________________________ PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION Basement sq ft: Finished hnfinished 1st Floor, sq ft: 2nd Floor, sq ft: Garage/Carport:, sq ft: Deck/Covered Porch/Patio: # of NEW Bedrooms: # of NEW Bathrooms: PROJECT DESCRIPTION ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ 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: _________________________________________ Signature: ___________________________ Date __________ For handouts, submittal requirements go to: www.edmondswa.gov. To apply for permits, schedule inspections, or check application status go to: www.mybuildingpermit.com ĞŵŽůŝƚŝŽŶ ĐĐĞƐƐŽƌǇ ^ƚƌƵĐƚƵƌĞͬ ĞƚĂĐŚĞĚ 'ĂƌĂŐĞ EĞǁ ^ŝŶŐůĞ &ĂŵŝůǇͬƵƉůĞǆ &ŝƌĞ ^ƉƌŝŶŬůĞƌ EĞǁ ŽŵŵĞƌĐŝĂůͬDŝǆĞĚ hƐĞ ^ŝŐŶƐ dĞŶĂŶƚ /ŵƉƌŽǀĞŵĞŶƚ DĞĐŚĂŶŝĐĂů GENERAL COMMERCIAL 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 TANK Fill in Place Fill Material: _______________ Removal Size of Tank (Gallons) ___________ Critical Areas Determination: Study Required Conditional Waiver Waiver DEMOLITION Type of structure to be demolished: Square footage of structure to be demolished: AHERA Survey done? Y / N PSCAA Case #: Critical Areas Determination: Study Required Conditional Waiver Waiver PLUMBING FIXTURE COUNTS (New, Relocated 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 Water Heater - Tankless? Y or N Hydronic Heat Water Service Line Sinks Other: Toilets 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: MECHANICAL EQUIPMENT COUNTS (New and 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: MEDICAL GAS, AIR VACUUM COUNTS (New, Relocated or re-piped) Qty Qty Carbon Dioxide Nitrous Oxide Helium Oxygen Medical Air Other: Medical - Surgical Vacuum Other: GRADE/FILL/EXCAVATE Grading: Cut ______________ cubic yards Fill ________________ cubic yards Cut / Fill in Critical Area: Yes No GENERAL PROVISIONS 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.