BLD2020-0935+City_Application+9.8.2020_3.08.10_PM`4c. 189,0
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswa.ijov.
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: 515 Homeland Dr.
Parcel: 004-773-0000-1800
Lot /Unit/Suite #:18 Subdivision: Homeland
BUSINESS OR PROPERTY OWNER:
Name: Mike & Mary Dolan
Mailing Address: 515 Homeland Dr.
city/state/Zip: Edmonds, Wa. 98020
Phone #: 253-905-8942
Email: mwdmkd@gmaiLcom
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner?❑✓ Yes ❑ No
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 a c nge according to RCW
3.8.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: Mike Dolan
Mailing Address: 515 Homeland Dr.
city/state/zip: Edmonds, WA 98020
Phone #: 253-905-8942
E-mail: mwdmkd@gmaiLcom
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:
City/State/Zip:
Phone #:
E-mail
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE M
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Office use 0:,Iv
TYPE OF PERMIT (Provide Details on Page 2)
Accessory Structure/
Detached Garage
Addition
Demolition
Mechanical
❑�ewSr�ngle.Fam�fly/Du�plex
Plumbing
Fire Sprinker
Remodel
New Commercial/Mixed Use
❑ Re -Roof
:7g�Signs
❑Tank
❑
Tenant Improvement
R1 Other & Or
Remodel Permit fees are based on:
The volue of the work performed. Indicate the value (rounded to
the nearest dollar) of ail equipment, materials, labor, overhead,
and the profit for the work indicated on this application.
Valuation: 1 500.00
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished ❑ Unfinished❑
tst Floor, sq ft:
2nd Floor, sgft:AV
W
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: I # of NEW Bathrooms:
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: MIghabPolan
i d
f 9-8 -20
Signature: Date
Occupancy Group(s): Occupant Load(s):
Types] 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
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:
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:
Qty
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:
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:
imStudy Required ❑ Conditional Waiver❑ Waiver❑
Fill in Place ❑ Fill Material:
Removal ❑ Size of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
RADE/Fl Li 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.