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BLD2020-1238+City_Application+11.11.2020_10.55.57_AMBUILDING PERMIT APPLICATION Permit#: Development Services Building Division 121 5th Ave N / Edmonds, WA 98020 425.771.0220 For handouts, submittal requirements go to: www.edmondswo.aov. To apply for permits, schedule inspections, or check application status go to: www.mvbuildingpermit.com JOB SITE INFORMATION/LOCATION: (Where the work is taking place) Job Site Address: ( 0Z� � Lz� j 5 T Parcel: ©or7<2%DDn i0b40a Lot /Unie/Snitr#: 4 Subdivision: 21Y PA �iC BWSfNESS9B&PROPERTY OWNER: Name: NAP—P.IET FU-1 Mailing Address: t 0 Z'J G L e NJ Sl- City/state/zip: E Dr W A of 8 6 Zo Phone#: ZDlO • 954— 7042 Email: x: 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: Name of Applicant: K P- IGl Ti%i 4A N 5 b f-J Mailing Address: (Or7Z A LDM `Jf City/State/Zip: c{$0ZD Phone#: 4Zci ' 114 -7 IZ� E-mail: hao'onG�Q5LR11 Q7 �IDtYI1aL� rCmni' GENERAL CONTRACTOR: (If different from applicant) General Contractor: Dr, -,AL) P715N N E'ff Mailing Address: MCI W AVJ� W City/state/Zip:`� WNHWOOD 03� Phone #: ` ,{{ 2,� ' _;�00 ' 17g &p% E-mail: \kdahb�inrletia� cow�ca5t't�a� STATE UBI #: CITY OF EDMONDS BUSINESS LICENSE It: WA STATE CONTRACTOR L & I It: (CCB) & EXPIRATION DATE: f/,rogg -K cV14 NG/ TYPE �F PERMIT (Provide Details on Page 2) ®Accessory Structure/ Addition El Detached Garage Demolition 0 Mechanical New Single Family/Duplex Plumbing Fire Sprinkler Remodel New Commercial/Mixed Use Re -Roof Signs ❑ Tank Tenant Improvement 13 Other Q " 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: PROPOSED NEW sQUARE�FOOTAGE FOR THIS APPLICATION Basement sq ft: Finished❑ Unfinished El 1st Floor, sq ft: 2nd Floor, sgit: Garage/Carport:, sq ft: Deck/ overed Porch/Patio: `�, 7• #of NEW Bedrooms: It of NEW Bathrooms: VU,PLAG LD X22•�' OMEN r iXVA'COD DEZr=. 5A:M.E G1ZE.'LDt.A (LQM NEW 5(Al2�i- 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. y 5 Tj�i�T-SA N 58� Print Name: �TVWtJSUY' 11 •°i'2oui Signature: Date GENERAL COMMERCIAL DATA Occupancy Group(s): R, —'r7 I Occupant Load(s): Type(s) of Construction: V b Fire Sprinklers: Yes El NoM I WA STATE ENERGY CODE: If your project affe he building envelope, mechanical systems, and/or lighting, you rii st complete the appropriate WSEC forms. DEFERRED SUBMITTALS: All commercial bullOng permits that will require associated plumbing, mechanical, fire sp in r, and/or fire alarm permits are applied for separately. TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet EQUIPMENTMECHANICAL • and Relocated) BTUs Gas / Elec / Other Qry A/C Unit /Compressor Air Handler /VAV 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 • City QtY Clothes Washer Tub/Showers Dishwasher Backflow Device (RPBA, DCDA, AVB) Drinking Fountain Pressure Reductio egulator Valve Floor Drain/Sink Refrigerator Wate Supply Hose Bibs Water Heater -Tankless? Y or N Hydronic Heat Water Service Line Sinks Other: Toilets Other: GAS/FUEL CONNECTION COUNTS (New, Relocated. BTUs City BTUs Qty A/C Unit Outdoor BBQ/ Fire pit Boiler Stove/R VOven Dryer Water t Fireplace/ Insert Other: Furnace Other: DICAL GAS, AIR VACUL)f COUNTSME A (New, Relocated or re piped) Qty QtY Carbon Dioxide Nitrous xide Helium Ox en Medical Air Other: Medical -Surgical Vacuum Other: Type of structure to be demolished: p�G� Square footage of structure to be demolished: AHERA Survey done? Y❑/ No PSCAA Case #: Critical Areas Determination: Study Required® Conditional Waiver® Waiver❑ Fill in Place ❑ Fill Material: Removal ❑ of Tank (Gallons) Critical Areas Determination: Study Required Conditional Waiver Waiver Grading: Cut ) cubic yards Fill 1 cubic yards Cut / Fill in Critical Area: Yes ❑ No 71 77777 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.