Wartelle_Permit_AppBUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswa. ov.
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:���
Parcel:
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: _
Mailing Address: `� aisue- kA
City/State/Zip: :v.�a.. �., 'VJ A, � (
Phone #: aQU -� IS- OR
Email: Q�WcA�A� C.O
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. N
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: Ste,.++-t: 0,'_
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:_5 b a-7 4y y}h s� W
City/State/Zip: Re:w,,.�r�wLC.� -k\ cr'r.' ,�VJA I�tT{7
Phone #:S
E-mail: _Mg*y& '.��,�%O� �-rv��%1DJ1. CA
STATE UBI #: t-1 A_ D
CITY OF EDMONDS BUSINESS LICENSE #: $�)-7`�`7
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Office Use Only
TYPE Of PERMIT (Provide
Details on Page 2)
Accessory Structure/
Detached Garage
Addition
Demolition
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 pro for the work indicated on this application.
Valuation: �Q , (�
Basement sq ft: FinishedIVI Unfinished
1st Floor, sq ft:
2nd Floor, sq ft: 39S
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: tt of NEW Bathrooms:
ALA,.-
�`�.de..
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:
Signature: Dates)-u
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 if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE
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 City 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
d 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
Grading: Cut cubic yards
Fill
Cut / Fill in Critical Area
cubic yards
Yes ❑ No ❑
Waiver
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.