1141 VIEWLAND bldg permit apPLICATIONf nC. 1 S9"
BUILDING PERMIT
APPLICATION
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.gov.
PLEASE (VOTE: 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 call 425-771-0220 to schedule an intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address;
Parcel: 066(w�Y6 C 0o 0/�la O
Lot /Unit/Suite #: / }9 Subdivision:
PROPERTY OWNER:
Name: r/ CfIt/u�/
Mailing Address:
City/State/Zip: CJ AA
Phone #: D �P �o @f '2
Email: 4
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ Yes O'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:
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
GENERAL CONTRACTi
General Contractor: f5'
Mailing Address:
City/State/Zip:
Phone #:
E-mail
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Office use Oriy
DetailsTYPE OF PERMIT (Provide on Page 2)
❑ Accessory Structure/
Addition
Detached Garage
emolition
❑ Mechanical
WdNew Single Family / Duplex
❑ Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
❑ Re -Roof
❑ Signs
❑ Tank
C1Tenant 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:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:�
2nd Floor, sgft:
Garage/Carport:, sq ft:
/
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT•
� �c�'DG ti-cam
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
Fdmonds.
Print Name:
Signature: Date 3 y
GENERAL • 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
EQUIPMENTMECHANICAL
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 ifa Commercial Bldg)
Other:
PLUMBING FIXTURE COUNTS (New, Relocated or re -piped)
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
s
Other:
Toilets
Other:
CONNECTION- - • -r or • r-r
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
/
Boiler
Stave/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
Other:
COUNTSMEDICAL GAS, AIR VACUUM
Relocated ..
Qty City
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum Other:
DEMOLITION
Type of structure to be demolished:
i �Si72
Square footage of structure to be demolished:
AHERA Survey done? Y / N
PSCAA Case #:
Critical Areas Determination: r""Zdt1/'9'f_9
Study Required Conditional Waiver ❑ Waiver ❑
WEEMEEMEMM10
Fill in Place ❑ Fill Material:
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
GRADE/FILL/EXCAVATE
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, Z 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.