City Application'4C. I Sy.
BUILDING PERMIT
APPLICATION rPermi�t#:
Development Services
Building Division
121 Sig Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswa.aov.
To apply for permits, schedule Inspections, or check application status
go to: www.mvbuildinanermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: P 117 9� ft Lt�MCN/% f✓ t7CC
Parcel: 06/ V 00sr6s :S-00606,700
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: -
Mailing Address: 1010, /;?O x `I GS_
City/State/Zip: rw i S'je it W 4
Phone #: '2-o6 V 'Z 3 ' �1 3yO
Email: i.✓�41,i�A-; N���ti/,,�s j AVM;t-
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner?oYes❑No
I own, reside in, or will reside in the completed structure. This
installation is being made on property that,l own which is•not
intended for sale, lease, rent, or exch ge a cording to RCW
18,27.090,
Owner Signature: c'M
APPLICANT / CONTACT INFORMATION:
Name of Applicant:
Mailing Address:
City/State/Zip: _
Phone #:
E-mail:
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
STATE UBI M
CITY OF EDMONDS BUSINESS LICENSE M
WA STATE CONTRACTOR L & I M (CCB) & EXPIRATION DATE:
TYPE OF PERMIT (Provide
Details ..
(� Accessory Structure/
Addition
Detached Garage
Demolition
Mechanical
New Single Family/Duplex
Plumbing
Fire Sprinkler
a Remodel
ETNew Commercial/Mixed Use
Re -Roof
Signs
Tank
Tenant Improvement
Other E
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:
PROPOSEDNEW SQUARE FOOTAGE.
Basement sq ft: Finished❑ Unfinished
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck Covered Porch/Patio:
6 a0 S �'�•
# of NEW Bedrooms: # of NEW Bathrooms:
PROJECT` DESCRIPTION
9 PLA-C/,uK Rnig
-5 o&J 47xi57-/A)4
DE Ce., ALSO M
iA), (2N ~7-0
Ni iJ 6 (9AK,i�PAILIVIS'S
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:/ A
r�
Signature:./�?_
Date "15-- 21
GENERAL COMMERCIAL DATA
Occupancy Group(s): 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: 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
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
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:
PLUMBING FIXTURE COUNTS (New, Relocated or re piped)
Qty City
Clothes Washer
Tub/ Showers
Dishwasher
Backflow 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:
GAS/FUEL CONNECTION COUNTS (New, d or re..
BTUs Qty BTUs City
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace Other:
MEDICAL GAS, AIR VACUUM COUNTS
Relocated or • •.
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:
AHERA Survey done? Y[]/ N[]
I 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
•. r)E/F ILL/ EXCAVATE
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill In Critical Area: Yes ❑ No
GENERAL
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.