BLD2021-0168+City_Application+1.29.2021_12.42.52_PM+20213451/1t,. I Ky�-'
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 Sth 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.mybuildinapermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 16036 68th Ave W
Parcel: 00513100004614
Lot /Unit/Suite #: 3 Subdivision: HPIIPrPn Hnmp.S
BUSINESS OR PROPERTY OWNER:
Name: Cecilia White
Mailing Address:
16036 68th Ave W
City/State/Zip: Edmonds, WA 98026
Phone #: (206) 954-4145
Email: lee.michaelis@pugetsoundplanning.com
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? Yes 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: Lee A. Michaelis
Mailing Address: 5005 200th St SW, Suite 101-B
City/State/Zip: Lynnwood, WA 98036
Phone #: (425) 830-1046
E-mail: lee.michaelis@pugetsoundplanning.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: Property Owner
Mailing Address:
City/State/Zip: _
Phone #:
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & 1 #: (CCB) & EXPIRATION DATE:
Office Use Only
(ProvideTYPE OF PERMIT
Accessory Structure/
Detached Garage
Details on Page
Addition
Demolition
1-1 Mechanical
New Single Family/Duplex
Plumbing
Fire Sprinkler
W1 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.
Valuation: $22,500
PROPOSED.. FOR THIS APPLICATION
Basement sq ft: Finished❑ Unfinished❑
1st Floor, sq ft:
0
2nd Floor, sq ft:
0
Garage/Carport:, sq ft:
0
Deck/Covered Porch/Patio:
0
# of NEW Bedrooms: 0 # of NEW Bathrooms: 0
PROJECT
Kitehen-Remodel to
include removal of
existing interior walls
three exterior
windows. Other
revisions include
cabinetry, countertops
and appliance
replacement
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: Lee A. Mich elis
Signature: Date 01/27/2021
COMMERCIALGENERAL 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
2
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE or 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
2
Other:
Toilets
Other:
CONNECTION COUNTSd or re piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ / Fire pit
Boiler
Stove/Range/Oven
2
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace Other:
COUNTSMEDICAL GAS, AIR VACUUM
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? Y❑/ N❑
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
..
Grading: Cut cubic yards
Fill 0 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.