BLD2020-0941+City_Application+9.9.2020_6.54.40_PMBUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5Ih Ave N { Edmonds, WA 9902G
,qV. I K%j'. _77l_Q22Q
Far hnn�pkit5, 3UI}mittal requlrcrnents, pLiMit SteLkrS Ind inSpeCtton
scheduling mformatian go to; www,rv¢n7orss15V+�k
PLFASf NOIT, Intake appointments are required for New Single Eamrly
Residences, Large Addittons, ADLI+sr rsrrw Commercial, and rl+fnjar Tenant
Improvernerrt applIcimori #ubrrtilltdls, If plans are prepared by d prof eSsiOn-
al, electrank files are requested In addition to the hard copies. Please bring
electronlc files on a flash drive or coordinate for eiectronit transfer.
Piense tall 425-771 •U220 to srhedu�r an intake appai`rrtm errtl
J 0 6 SITE INFORMATION/LOCATION: (Where the work Is taking place)
r+F
Job Site Address; ZI 6r l 121i A W. 802 h
Parcel
Lot JUnItfSuite R. all SubdivIsfon:
PROPERTY OWNER:
Name; 1-1)11PA TW TfAj
Mailing Address: 2 � 6 Of " pt Li
cky/5tatejzlp: EDMONDS WA 2802.6
Phone #. 2 0.is 216
Small; roe h0 .
{
OWNER 1 STA I.ATION: *If yes, read antl sigma
WilII work bE performed by the property owner? ❑ Yes IxNo
I awn, reside in, or will reside in the completed structure. This
Installation is being made on property that I own which is nut
intended for sale, least, Tent, or exchange according to RCW
18.27.09 D.
Owner Signature:. 'f -fe
APPLICANT f CONTACT INFORMATION,
Name of AppIIcant«
Mallfng Address., _
City/state/zlp:
Phone #;
E-mail
GENERAL CONTRACTOR: (If different from applicant)
General Contractor; Aq H
Mailing Address
City/state/zlp:
Phone #:
E-mail;
STATE UBI P.
CITY OF EDMONDS BUSIN E5S LICENSE If;
A STATE CONTRACTOR L & I if; {CCO) & EXPIRATION DATE;
Ulrir_f� tl3c Only
❑ AccessoryStructuref
E_I Addition
Dctarhad Gar,,gr,
fJ Demolition
Ea Mechanical
❑ New Single Family! Duplex
❑ Plumbing
❑ Ffre Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
❑ Re -Roof
❑ Signs
❑ Tank
❑TenantImprovement
her F—e,rl +
Remodel Permit fees are bated on,
Tlee value of the work performed.In6cate
the valve (rounded la
the nearest dollar) of all equipmenI. muleRols. labor. overheod.
-.ncl the profit for I" wank Fndica led on finis 10l3p alion.
Valuation: Or'16cx 00 L'-1' rYk<?hnt .ti{
C+,i ., nuiit• sq ft: Finished ❑ Unfinished 0
1st Floor, sq ft;
gird Ffoar, sq ft;
Garage/Ca rport ', sq k: 5
I Deck/Covered Porch/Patio: I I
Other sq R:
I certify I hal I he Information 1 bawe pravrded on tnl s form japptication i s true,
ca(rett arsd tom plate, a nd that t am the prop#n y owne+ or duly a ui horlmd
agent of the property owner Ia sut)mg a permit a pplrca#1on to f he Ciky of
Edmonds,
Print Name.
Signature: r' Date _�
0CcupancyGroup(5); I DeeupintLoad[s);
Types) of COnStructiart; Flre Sion nklers= yes ❑ KFp ❑
WA STATE ENERGY CODE; If your project affects the bulIdIng envelope,
mechanlraI systems, and/or rl�hting, you must Complete the
appropriate W5EC forms,
0EFERREDSUBMITTALS= All cnmmercialbulldingperrnitsthat will requlre
asfioriated plumbfrrg, inerhanlca1, fire sprinkler, and/or lire aI&M
Prm45 are applled for Separately,
Tf 1 CHANGE OF USE J NEW BLDG; Include TPAFFIC IMPACT wofWia2t
BTUs Cas{Elec/Other Qtv
A/C Unfit /Compressor
Air Handler /VAV
�CFUCr
Dryer Duct
Exhaust Fans
Fireplace
Purnare
Meat Pump Unit
HydronIc Heating
Roof Top Unit 1prayltle eleva-
tions If d {ammerclal BId6j
Other,
I
Qty City
Clothes Washer
Tub/Showers
Dishwasher
�`
9nVow Device (APEA, OCDAr AVI})
DrinkingJ70vntain
PressureAeduction/RegulatorValve,
FloorDraiii/Sink
RekigeratorWater Supply
Nose Bibs
Water Heater - Tarlkless? Y or N
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other;
BTUs
Relocated Yre-pi {
Qty BTUs QtY
A/C Unit
Outdoor BBQ / Fire pit
Boller
Stay+/Range{Owen
Dryer
Water Heater
Flreplacq Insert
Other;
Furnace
Other:
located!1 Y
Oty Qty
Carbon Dloiddo
NitrousOxide
WrrlYurri
Oxygen
Medial Air
Other;
Medical • Surgical Varuum {]Cher;
Type of structure to be dempflshed;
Square footage of Structure to be demolished;
AHERA Surveydprse? YIN
PSCAACa$aM:
VMCaI ,areas oetermination;
5tudv19equired ❑ Candlpgnal Waiver ❑ Waiver ❑
Fill In Plare ❑ Fifl Material:
Removal ❑ [ Size of Tank (Gallons)
CFMraI Area& determIrratlon;
SWdyFequlred ❑ Conditional Waiver ❑ Waiver ❑
Grading: Cut _ rubic wards
Fill
cublC yards
Cut 1 Fill Ir} Critical Area- Yos Q No ❑
APPLICATIONS; Applications are valid far a rri;ixlmum of 1 year.
E5i_WA Appicatians, 2 years,
LICENSING; All contractors and subcontractors are requited to lb ilcerlscd
with Washington State Oapartment of Labor & Industrles and have a
CUr{erlt City of Edmonds Bslslne55 License.
GENEKAIL COMM EWAL DATA
Otcupan€y Ciroup(s); DCcupint Load[sj;
TYkE(S) of COnstFUCdCn, Flre Sion nklors= Yes ❑ rF0 ❑
WA STATE ENFRGY CODE; If your project affects the building envelope,
mecho nlraI syst-nms, and/or IISh#ing, You must Complete the
appropriate W5EC forms,
DEFERRED}SUBMITTALS= All rnmmercialbulldingpermitsthat wJllrequlre
associated plumbing, mechanical, fire sprinkler, end/or fire a18FM
permits are appiled for Separately,
TI / CHANGE OF USE J NEW BLDG; Include TRAFFIC IMPACT wofksheet
COUNTSRACCHANrCAL EQUIPMENT +
BTUs Ga.; f Elet / Other Qt-Y
AIC Unit /Comlam ssor
Air Handler /VAV
0pIIcF
Dryer Duct
Exhaust Fans
Fireplace
Purnate
k
Heat Pump Unit
Hydranit Heating
Roof Top Unit fprowide cleva-
ilana If a COMFnerclxl BId6j
Other
PLUMBING
FIXTURE
COUNTS {New, Relocated
or re
-piped)
■
Clothes Washer
Tub/Showers
ENshwasher
�`
Rnkflow device tPPOA, DCDA, 06)
Drinkrngl=ountaJn
PressureAeductiorr}ROSLelatorValve,
Floor Drain/Sink
Refrigerator WMer Supply
Nose Bibs
Water Heater - Tankless7 Y or N
Hydronlc Heat
Water Service Line
Sinks
Other,
Tpllets'
Other;
•
+ ,
STUB
Qty BTUs Qty
A/C Unit
Outdaor 8RQ / F,re pit J.
Bo+ler
Stove/Range/oven
Dryer
Water Heater
Flreplace/ Insert
Other;
Furnace
Other:
r
Uly Oty
Carbon Dioxide
NiCruuspxido
HelMurri
OHYgen
Medical Air
Other;
Medical • Surgical Varuum
anther;
Type of structure to bE demprlshed;
Square footage of structure to be demolished;
A„ERA Surveydone# YIN
PSCAACase if:
Critical Areas DeterminaLion:
Study Required ❑ Con dininnal Waiver ❑ Waiver ❑
FilI In Place ❑ Fill Material:
Aemoval ❑ [ Size of Tonk (Gallons)
Critical Area& detefmlrnation;
Study fat:quired ❑ Condltianal Walvef ❑ Waiver ❑
Grading: Cut cubic yard&
Fill
CUIbIC yardS
Cut / Fill In Critical Area- Yin Q No Q
APPLICATIONS; Applications are Wand for a rrtilxlmum of 1 ye,1F,
ESCHA Applications, 2 yeaFs,
LICENSING, All contractors and subcontractors are required to Eta Ilcerlscd
with WashlWpry State Department of Labor & Industrles and have a
current City of Edmonds U5ines5 License,