APPLICATIONBUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425. 771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edmondswa.gov.
PLEAS E NOTE: Intake appointments are required for New Single Family
Residences, Lorge 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
electronic files on a flash drive or coordinate for electronic transfer.
Please call 425-771--0220 to schedule an Intake appointment!
JOB SliTE INFORMATION/LOCATION: (Where the work Is taking place)
Job Site Address: G, S S VI ~ W ~
Parcel: QQ5q~'90QO 30~,0Q □Tenant Improvement D Other _
~..LU_r:iJtiS.tJ.iJ.e_j/; 303 SJi...b_division: CPrlZ..M EZ-- . ---
. ~ 01;)0 '-ti i-j1\JM Remodel Permit fees are based on:
PROPERTY OWNER: The value of fhe work performed. Indicate the value [roonded to
Name: ])l;'N ~l $ 1f, S \J"'.7~ LA-ti\J~'-/ the nearest dollar) of oil equipment, mate~als, la~or._ overhead.
· and the profit for the work indicated on thls application.
Mailing Address: (e S 5 YI{( N s.-r- ;:;1:t ::SO<.
City/State/Zip: @ f\60 ~t)'S,, WA q8020
Phone#: l--JY: ~ - "c>4-0- 8 3Cfb
Emai I: W ~ f..) I ~ 1> L,A~Q::/ @ ld-'OTuA'U.A COi
OWNER INSTALl!ATION: *Jf yes, read and sign• /
Will work be performed by the property owner? D Yes ll!'No
f own, reside in, or will reside in the completed stru~ur~. lihis
installatton Is being made on property that I own which 1s not
intended for sale, lease, rent, or exchange according to RCW
1!8.27.090. I""\ -·._ "Y, ~~
Owner Signature: ~v~ • ~
APPl;ICANif / CONTACT INFORMATION:
Name of Applicant ])1;5).J r-.A <:; p, 1,..-Al,..) t>O..'j
MailingAddr.ess: (,,,55 \:1A:H) $1 * "303
• •• I ~£020
TYPE OF PERMIT (Provide Details on Page 2)
D Accessory Structure/ D Addition
Detached Garage
D Demolition □ Mechanical
D New Single Family/ Duplex D Plumbing ~ g
D Fire Sprinkler Remodel
D New Commercial/ Mixed Use D Re-Roof
□Signs D Tank
Valuation:------------:-==
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished 0 Unfinished D
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
!Deck/Covered Porch/Patio:
Other sq ft:
PROJECT DESCRIPTION . .
\\C\~ C...f;tl-1 K) G
Phene#: H(...(-=3-~U'{) -~3,Cf b
E-maik ~fv I~ l> L-tnJOP--Y Q krf;11lA ~ ( l, o:,v\
GENER~L C0NiTRACliOR: (If dlffe~ent from applicant)
Gemer,al <i:ontraotor: &71 M Po, ({)V \ \-J A
Mailing Ad~r.ess: 2( ~ 'l '2.. zlb'1k PL • W '
City/St!ate~ip: ~b M,Qrv b$) WA q~ 02,b
Phone#: Q-{Z.5) 2..l:3-b332.
E-mail: I NE:::O g} AS l(.() (l),-) ~TI2,\,£Trt() 1
STvAlJ!E l!IBI #: _
€1iF( (!)F El!>M0Nl!>S Bl!JSINESS 1!!1€ENSE #: _
W/JI. Sl!'A;i!E Cil0NiliRA€ili 0R t & I #: (CilCB) & EXPIRA11110N l!>AlflE:
Q,~\ OVXT1 w '(5-
o ru oc ~At \~GH-1. WAS
\./4)~ B-Y {?\l,~\)(OU!'> t:tj)~
$0 k, S TO ~\JO\ D A ~L>L-~t~
t\j:p\J~ \.G\~~ ~t~~,
(0v"V\J"6 ~ ~ ?Q1\V \j l !)0.::>)
I certify that the lnformattonu have provided on this form/application Is true,
correct and complete. andnhat 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: l:)~ r-.> CS,. ~ ~1
Signature: Bate _
et Furnace Other:
lty
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:
DEMOLITION
Type of structure to be demolished: \< \ ,-C~ C el L l ~ G
q• 4 I X · I -, I I -
Square footage of structure to be demolished: ; ~ • L.. ..,..
AHERA Survey done? Y / N PSCAA Case #:
Critical Areas Determination:
Study Required D Conditional Waiver D Waiver D
TANK
Fill in Place D Fill Material: -------
11 Removal D Size of Tank (Gallons) _
.•
ty
Critical Areas Determination:
Study Required D Conditional Waiver D Waiver 0
GRADE/Fl LL/EXCAVATE
Grading: Cut cubic yards
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