demo permit"Ic. t 89�j
BUILDING PERMIT
APPLICATION Permit #:
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.eamondswa.gov.
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 cal! 425-771-0220 to schedule an intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 2 17 0$=616",4yE. W• F%#-^opbs
Parcel: 003736— 007— 006 — 02
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: HL M. P0&0 YA-IN
Mailing Address: 23 S 2—I j t3X & P_ P �•
City/State/Zip: & 2 , !P Q C? G 03
Phone #: ZO G -- qd? 2 — G 9 f 6
Email: ! G 41- P—OC o 40 6MAi'L • CCoM
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? r3yes ❑ 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: AL. /t•/1 • �i�r�OGO `1r� /i-ej
Mailing Address: 2-S `ZS {7 �,�' G P_%1
City/State/Zip: &3n3 tEe 19036
Phone #: 206 - 4? Q Z - (�
E-mail: 1Na 4L 2_,pco GM/�r�G �GY41
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: n /4L
Mailing Address:
City/State/Zip: _
Phone #:
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & 1 #: (CCB) & EXPIRATION DATE:
TYPE OF
❑ Accessory Structure/
Detached Garage
Details on Page
❑ Addition
emo1ition
❑ 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,
and the profit for the work indicated on this application.
I Valuation:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft.
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT•
�tmr,oitish �xl'S�inq s•>�2k�-line
I
i
i
i
I
I
i
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.
Print Name:/#Ij',tELAL D•A IJ
Signature ate
GENERAL COMMERCIALDATA
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. • . ..
Qty Qty
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, Relocated or re -piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace Other:
MEDICAL / AIR VACUUM•
Relocated . • .
Qty QtY
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum Other:
DEMOLITION
Si NGL� F '
Type of structure to be demolished: �i'M�Gy
Square footage of structure to be demolished: 8 0 S S It",
AHERA Survey done N
PSCAA Case #:�OZQ7 gJr�
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver L_
Fill in Place ❑ Fill Material:
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
•.D
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
GENERALPROVISIONS
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.