BLD2020-0958+City_Application+9.15.2020_6.20.56_AMloc. 1013
BUILDING PERMIT
APPLICATION Permit #:
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswa.gov.
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 Addrress:'A� / � Ck a n/ Cvti i e 3ov,,6, V,4-
Parcel: 0C13ciL cc ?oo i o c
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: LA VILcx,A\
Mailing Address:
city/state/zip:r \ �2 ty A $�
Phone #:ac. trr_ L,
Email: 'fJic-1 "' NJ
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. his
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:
MailingAddress: r C
City/State/Zip: -r K3gti /l � o 0
Phone #: a �� 1 , (;:-e) o
E-mail: Cast ���!►�.i RJ6 �� . � , �;✓1.
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: L`ydy�Cs+ f�
Mailing Address: / ; V.V
City/State/Zip: `
Phone #:
E-mail: q
STATE UBI #:6 1
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
(ProvideTYPE OF PERMIT
Accessory Structure/
Detached Garage
Details ..-
Addition
Demolition
Mechanical
New Single Family/Duplex
Plumbing
Fire Sprinkler
❑ Remodel
New Commercial/Mixed Use
Re -Roof
TT❑��
Signs
❑ Tank
Tenant Improvement
❑ Other
Remodel Permit fees are based on:
II IC. vu1VC VI II IC WVIR ym I VI I I ICU. II Iull_u l C II IC vulUC IIVUIIu Cu IV '.
the nearest dollar) of all equipment, materials, labor, overhead,
and the profit fpr the work indicated on this application.
Valuation:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement scl ft: Finished❑ Unfinished❑
1st Floor, scl ft:
2nd Floor, scl ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
1 PROJECT•
C \
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: is
Date Signature: �-'"'�