applicationor I:r�,1, BUILDING PERMIT
-f o APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
"V I x q o 425-771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: httj):j/www.edmondswa. ov/
JOB SITE INFORMATION/LOCATIoN: where the work is tatting Pam)
Job Site Address: AP4 2=-o 0
Parcel: D51 21^ 0 0 0 Do 4 00
Lot /Unit/Suite #:k Subdivision: sJ»sl- �4dd
PROPERTY OWNER:
Name: JQ1ktJ t GVA-tP-C NA61Z-ew?
Mailing Address: , � g3e4 nvC W
City/State/Zip: VV01
Phone #:
Email: Seotvv%Virw 1^ LEA �J��•GM: r lat�snt�rtol►e
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ Yes M"'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 19.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: 4VA D ► k-crr L_ (i ESQ N //4lLhi-i� S
Mailing Address: t 1-" ".v"...zLC. WAk. #N 31�tSt�.,
City/State/Zip: o Ac.. WA 9 Iv
Phone #: 2-0 454 2.
E-mail: kkki a i%?_ A"oki ftepK• Prim
GENERAL CONTRACTOR(if different from applicant)
General Contractor: 6ff 92.5L'j(e4Aia
Mailing Address: q. o . 16 a >r 6 ;_ Y,
City/State/Zip: ' 4t W , ewt S, k4- 9 a Z
Phone #: �. D � � ` � 4 (z ?
E-mail: pIV`A `tLtrvs Af A.. fe&6f7AA • G+M
WA STATE CONTRACTOR L IL 1 # (CCB) i EXPIRATION DATE:
1I P_f,SRC- R(5-mt- 7/1/Z02.1
CITY OF EDMOINDS BUSINESS LICENSE M
Permit 2 'L1
❑ Accessory Structure/
Detached Garage
Demolition
❑Addition
11Mechanical
w Single Family / Duplex
❑ Fire Sprinkler
❑ Plumbing
❑ 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: g p o p a o
Basement sq ft:Finished ❑ Unfinished ❑
1st Floor, sq ft:
, 1; (, I C2ic
2nd Floor, sgft:
g' $ 5-- & sr
Garage/Carport:, sq ft:
3-7 3 1 ` 5f
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT DESCRIPTION
` +. s
I certify that the information I have provided on this form/application is true,
correct and complete, and that 1 am the property owner or duly authorized
agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: +
Signature: Date ii G 1
fi
✓0
Occupancy Group(s): Occupant Load(s):
Types) of Construction: Fire Sprinklers: Yes ❑ No ❑
WA STATE ENERGY CODE: If your project affects the building envelope,
mechanical systems, and/or lighting, you must complete the
appropriate WSEC forms.
DEFERRED SUBMITTALS: All commercial building permits that will require
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor
Air Handier /VAV
Boiler
Dryer Dud
�� �i✓
I
Exhaust Fans
f, to C.
Fireplace
2J1 3 o a
' ^el
Furnace
Lot 3 ♦
GI
1
Heat Pump Unit
eAi G
Hydronic Heating
Roof Top Unit (Provide eleva
tions H a Commercial Bktg)
Other:
Qty City
Clothes Washer
Tub/ Showers
Z
Dishwasher
,
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
Q
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Sulky
Hose Bibs„
Water Heater - Tankless? J�Lr N
Hydronic Heat
0
Water Service Line
Sinks
Other:
Toilets
rl
Other:
BTUs clry BTUS City
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Z$k
Other:
Furnace
6p i Other:
Qty
Qty
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical -Vacuum Other:
Type of structure to be demolished:
Square footage of structure to be demolished: �j rjF
AHERA Survey done? Y / N
PSCAA Case p:
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ h1l Material:
Removal ❑
& of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Grading: Cut w 'L- cubic yards
Fill Q2 cubic yards
Cut / Fill in Critical Area: Yes_❑ No
APPLICATIONS: Applicatr*ns are valid fora maximum of 1 year.
ESLHA Applications, 2 years.
LICENSING: All contractors and subcontractors arerequired to be licensed
with Washington State Department of Labor & Industries and have a
current City or tdmonds Business ucense.