BLD2020-0876+City_Application+8.19.2020_12.21.11_PMle, l tS'
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswa.pov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildinapermit_com
JOB SITE INFORMATIONNf LOCATION: (Where the work is taking place)
Job Site Address: -i r7 Vtiair�!'' l7�
Parcel: 6 0 417 6C 20) 20 I S'OD
Lot /Unit/Suite #: Subdivision:
BUSINE55 OR PROPERTY OWNER:
Name: ✓ i'I4
Mailing Address: '� 5 ft� Wet6l ul rJ -
City/State/Zip: r-,d m ciriA V ZO
Phone #:
Email: .)Iyy%yYl O +�O C1t7✓��OOic-, tip^,
.OWNER INSTALLATION: *If yes, read and sign'
Will work be performed by the property owner? ❑yes No
I owns, reside in, or will reside in the completed structure. This
installation is being made on propert that I own which is not
intended for sale, le a ang ac ordinj to RCW
18.27.090.
Owner Signa
APPLICANT / CONTACT INFORMATION: jj f
Name of Applicant. 0A id IGtIG�
Mailing Address: Zl t0 { �� �iC-•V1f G1slr�c
City/State/Zip: �L/Y1W�dd� V\/A 9►15 24'L
Phone
E-mail: Gl ae Ile-6ef,o.,.jef jjC:�r-_v g �9a If%towt
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:_
City/State/Zip:
Phone #:
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
�:)ifice Lke Cni,
TYPE OF PERMIT (Provide Details on ..
❑Accessory Structure/
Addition
Detached Garage
Demolition V W
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, lobor, overhead,
and the profit for the work indicated on this application.
Valuation: 1150, ooO' d�
PROPOSED NEW SQUAREFOOTAGE
Basement sq ft: Finished ❑
.• THIS APPLICATION
Unfinished❑
i
1st Floor, sq ft:
t T ir LJ• ' i
2nd Floor, sgft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
PROJECT DE5CRIPTION
— c emes-e deG e
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: _ VGv-jj� VeMe4tetr
Signat6r ,;� - Date ��) q he
GENERAL COMMERCIAL DATA
Occupancy Groull Occupant Load(s):
Type(s) 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: Ali 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
MECHANICAL EQUIPMENT •
BTUs Gas / Elec / other Qty
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 ■ • or • r-•
Qty Qty
Clothes Washer
Tub/ Showers
Dishwasher
Rackflow Device (RPBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
Water Heater-Tankless? Y or N
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other
CONNECTION • Relocated or • .
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Fumace Other:
COUNTSMEDICAL GAS, AIR VACUUM
d or re piped)
Qty
Qty
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical -Surgical Vacuum Other:
DEMOLITION
Type of structure to be demolished:
Square footage of structure to be demolished:
AHERA Survey done? YEI/ NQ
PSCAA Case #:
Critical Areas Determination:
Study Required❑ Conditional Waiver❑ waiver❑
Fill in Place ❑ Fill Material:
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
.D
Grading: Cut cubic yards
Fill Iry 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.