Building_Permit_Permit_Application_2019BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
'"C C. 1 8 y" 425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edmondswa.gov.
PLEASE 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 appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 19303 80TH PL W , EDMONDS, WA
Parcel:
00572700001800 98026-6219
Lot /Unit/Suite #: 18
PROPERTY OWNER:
Name: Nader Harb
Mailing Address:
City/State/Zip: _
Phone #:
Email:
Subdivision: C
19303 80TH PL W
EDMONDS, WA 98026-6219
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:
Dennis Titus
Name of Applicant:
Mailing Address: 250 4th Ave S
City/State/Zip: Edmonds WA 98020
Phone #: (425)-778-8500
E-mail: Dennist@cgenineering.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: Tersull Construction
Mailing Address: 1550 NW 49Th
City/State/Zip: Seattle, WA 98107
Phone #: (360)722 0682
E-mail: matt@tersuli.com
STATE UBI #: 602-913-186
m
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
CCTERSUCS891 D10 3/16/21
Office Use Only
TYPE OF PERMIT (Provide Details on Page 2)
❑ Accessory Structure/ ❑ Addition
Detached Garage
❑ 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: $50,000
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECTDESCRIPTION
A fire has damaged an existing
single-family home. The fire damaged the
trusses and some of the wall framing on
the west side of the house. The damaged
framing will need to be removed an
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.
Dennis Titus
Print Name:
Signature: Date
COMMERCIALGENERAL
O ancy Group(s): Occupant Load(s):
Type(s) of Cons 'on: Fire Sprinklers: Yes ❑ No ❑
WA STATE ENERGY CODE: ur project affects the building envelope,
mechanical systems, and/or ng, you must complete the
appropriate WSEC forms.
DEFERRED SUBMITTALS: All commercial builds ermits that will require
associated plumbing, mechanical, fire sprinkler, a r fire alarm
permits are applied for separately.
TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet
EQUIPMENTMECHANICAL •
BTUs Gas / Elec / Other Qty
Unit /Compressor
Air H\r1rVAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE
Qty Qty
es Washer
Tub/ Showers
Dishwashe
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
RN4.erztor Water Supply
Hose Bibs
Water Heat - Tankless? Y or N
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
CONNECTION COUNTS.. .. .
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Heater
Fireplace/ Insert
Other:
Furnace
Other:
MEDICAL•
Relocated .
Qty Qty
Carbon �e
Nitrous Oxide
Helium
Oxygen
Medical Air
Othe .
Medical - Surgical Vacuum
Other:
DEMOLITION
Type ructure to be demolished:
Square footage of struct be demolished:
AHERA Survey done? Y / N
PSCAA
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
900000002000000
Fill in Fill Material:
Removal ❑
nk (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Grading: Cut 0 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.