permit application copyInc. 199"
BUILDING PERMIT Only
APPLICATION Femnit #:
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edmondswa.Fov.
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 ca11425-771-0220 to schedule an Intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work Is taking place)
Job Site Address: V Dozo 95- " ��• W
Parcel:
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:{
Name:
Mailing Address:
City/State/Zip:
Phone #:
Email: a e UtUeDKIC.(AS'�'QCV
OWNER INSTALLATION: *If yes, read and sign'
Will work be performed by the property owner? GYes ❑ No
own, reside in, or will reside in the completed structure. This
installation is being made on property that I own which is no
intended for sale, lease exchange a ing to
18.27.090.
Owner Signature:
APPLICANT/ CONTASTINFORMATION:
Name of Applicant: �K`�� ` h ,
Mailing Address: C 5` vv
City/State/Zip.. V`O �+S vv J\ v , 302(
Phone #: 2,-0� �",�("�����
E-mail: d.i�r���ur 6f-M@
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:-
City/State/Zip:
Phone M
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE M
DetailsTYPE OF PERMIT (Provide
❑ 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,
:nd the profit for the work indicated on this application.
i
aluation:
j easement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft: in f
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
d���v��v�rn WWII pe�motn�ho�
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. ���e ��
Print Name• _ ,
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE: I I �r ,..��,�f if� �_ /� 'Date
COMMERCIALGENERAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes ❑ N
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
EQUIPMENTMECHANICAL •
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor h
Air Handler /VAV /
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
i
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE . .r re-piped
Qty Qty
Clothes Washer iYA Tub/Showers
Dishwasher ` Backflow Device (RPBA, DCDA, AVB)
Drinking FountaiVee
duction/ Regulator Valve
Floor Drain/Sink Water Supply
Hose Bibsr-Tankless? Y or N
L[Hydronic Heate Line
s
GAS/FUIEL CONNECTION
BTUs
COUNTS (New, Relocated or re -piped)
Qty BTUs City
A/C Unit
VAj�
`
A
outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
Other:
MEDICAL•
.. ..
Qty
QtY
Carbon Dioxide
hG(
Nitrous Oxide
I f�
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum Other:
• • •MaliFINMI�Ivi
a:
Typ, , cf structure to be demolished:
Sq:,=re of structure to be demolished: �5
AHER.N Survey done? Y / N
TPSCAA Case q:
Critical Areas Determination:
Study Require Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material: h/G1
Removal ❑ I Size of Tank (Gallons) h `�
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Grading: Cut ir\/ 2�'1 cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
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.