Application-BLD2020-0197°e. 1 Sys
BUILDING PER
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 ov.
ELEASE NOTE: Intake appointments are required for New Single Family
Residences, Large 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 call425-771-0220 to schedule an Intake appolntmentl
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address:
Parcel:
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: 1VATION LAND
Mailing Address: 119 II C)PDVII .,F e r NW
City/State/zip: _MRcsII I n►.I Qfli L1'4L4-7_
Phone #: 3o 3. 832- • 4o 9 I
Email: erA, I1Se na+on Land t, fy F tk q .m
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: vltil M
Name of Applicant: L% JNlA) DU
Mailing Address: 2-1 A WMvilm) mp&L
City/State/Zip: _ fYIQKKCW, WA; �gD3Jp
Phone #: If-L3-`7-7t . 0 7 QG1
E-mail: +3 @ FAA rS16rM&. (,DM
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI M _P 0-3 r 3 B 3915 �h
CITY OF EDMONDS BUSINESS LICENSE M Iv PI-02k)(V-%
WA STATE CONTRACTOR L & I M (CCB) & EXPIRATION DATE:
C c S Ts L z c�(rz3 r���N og 1 (0 20 20
I
rmit #: r - —fn
❑ Accessory Structure/
Detached Garage ❑ Addition
❑ 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: � 4 °d
Basement sq ft: WIF
1st Floor, sq ft: / t r ' 11
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
Finished ❑ Unfinished ❑
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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:
r�Signature: Date OI I--;;