APPLICATION-FERKINGSTADF.
e. I 9 o
BUILDING PERMIT
APPLICATION
Development Services
Building Division
12,l slh Ave N / Edmonds, WA ?8020
425.771.0224
For handouts, submjttal requirements, permit status and inspection
scheduling information go to: W€d-re,ndgègev.
PLEASE NOIE: lntake appointments are required lor New Single Family
Residences, I"orge Additions, ADU's, Neu¡ Commercial, and Moior Tenant
lmprovement applicatíon submittals. lf 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 cdll 425-777-a220 ta schedule an intake appoìntment!
Permil #:
JOB StrE TNFORMATTON/LOCAT|ON:is taking place)
Job Site
Parcel:
Address:i57 tç -I ¡l¿zI
Lot /Unit/Suite #:
-
Subdivision
PROPERTY OWNER:
Name:
Mailing Address:
City/State/Zip:
Phone #:
Emaíl:
OWNER INSTAILATION: +lf yes, read and sign*
Will work be performed by the property owner?þves n rrro
I own, reside in, or will reside in the completed structure. This
installation is being made on property that I is not
RCW¡ntended for sale,
18.27 -O90.
Owner S¡gnature:
lease,
.-.j
APPLICANT / CONTACT INFORMATION:
Name of Applicant:A> â,
Mailing Address:
City/State/Zip
Phone f:
E-mail:
GENERAT CONTRACTOR: {lf from applicant)
General Contractor:
Mailing
City/State/Zip:
Phone #:
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE f:
WA STATE CONTRACTOR L & I #: {CCB} & EXPIRATION DATE:
tr AdditionI AccessoryStructure/
Detached Garage
n MechanicalD Demolition
D New Single Family / Duplex I Plumbing
I Remodeln Fire Sprinkler
I New Commercial/ Mixed Use ü Re-Roof
D Tank rI Signs
y o'n* ûldl,{/ l'\¿':Lfl Tenant lmprovement
Remodel Permil fees ore bosed on:
The volue of lhe work performed. lndicole lhe volue {rounded lo
the neoresl dollor) of oll equipmenl, moleriols. lobor, overheod,
for lhe workindicoted on fhis opplicolion.
,
Voluotion:
ond lhè
Finished I Unfinished DBasement sq ft:
1st Floor, sq ft:
2nd Floor, sqft:
Garage/Carport;, sq ft:
/*E7Deck/Covered Porch/Patío:
that the information I have provided on this form/applicatlon 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
Other sq ft:
¡
I
DateSignature:
Edmonds.
Print Name:
lYPE OF PERMIT (Provide Deioils on Poge 2)
PROPOSED NEW SqUNNE FOOTAGE FOR THIS APPLICATION
PROIECT DESCRIPTION
Occupant Load(s):Occupancy Group{s):
rype{s)of constructi$/ | /Fire Sprinklers: Yes Ü No I
affects the building envelope,
you must complete the
WA STATE ENERGY
mechanical
DEFERRED SUBMITTALS: /ll .ommercial building permits that will require
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
Tl / CHANGE OF USE / NEW BLDG: lnclude TRAFFIC IMPACT worksheet
BTUs Gas / Elec / Other qty
A/C Unit /Compressor
Air Handler /VAV
Boiler T
Ur]Dryer Duct
.ili\
I /-rExhaust Fans
I
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
QtvQtv
Tub/ ShowersClothes Washer
Backflow Device (RPBA, DCDA, AVB)Dishwasher
Regulator ValvePregsureilindau.tionlDrinking Fountain
,/"*r"e#ttersuppryFloor Drain/Sink
v[;/
watdr ud'ateî - Tankless? Y or NHose Bibs
Water Service LineHydronic Heat
Other:Sinks
Other:Toilets
GENERAL COMMERCIAL DATA
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
PLUMBING FIXTURE COUNTS (New, Relocated or re-piped)
BTUs Qty BTUs ary
Outdoor BBQ / Fire pitArlc unit
Boiler
{þveltanse/ovenI,Jl
/i$terHeaterDryer
I
Other:Fireplace/ lnsert
Furnace Other:
atv Qtv
Nitrous OxideCarbon Dioxide
Helium / t..1j^-J Oxygen
té
Other:Medical Air {
Other:Medical - Surgical Vacuum
Type of structure to be demolished
Square footage of
ERAAH Y?Survey PSCM Case #:
Critical Areas Determination:
Study Required fl Conditional Waiver fl Waiver I
Fill in Place I Fill Material
Removal I of Tank (Gallons)
Conditional Waiver D Waiver flStudy Required
Critical Areas
Grading: Cut yards
F¡II
NoDcut / Fill in critical
APPLICATIONS: Applications are valid for a maximum of l year
ESLHA Applications, 2 years.
LICENSING: All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & lndustries and have a
current City of Edmonds Business
GAS/FUEL CONNECTION COUNTS (New, Relocated or re-piped)
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or re-piped)
DEMOLITION
TANK
GRADE/FILL/EXCAVATE
GENERAL PROVISIONS