BLD2020-1171+City_Application+10.30.2020_8.39.59_AMBUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswa.gov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildinaoermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 101 "W 5mm'&t rL-p, 0_& IOA Mo7Z)
Parcel:
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: %-Fe,6A OUnFMAitl
Mailing Address: Z,�00'T VAWAk9r)pO
City/State/Zip: V.)0 aoi,UO /F IA)A ggOZ :>
Phone M l 7 ) "1i6 — 7.933
Email VAPEi✓F.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. 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:l(
APPLICANT / CONTACT INFORMATION:
Name of Applicant: �G�tC7 Qzg46I 'VjZ>
Mailing Address: I�A &_,wjET %VA. /l)
City/State/Zip: (—t7t�_DL. Wig �6OZJ
Phone #: (? ) �,1�
E-mail: �/%1Zp Q AFf-067, n1E r
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: V 6f 6Z:-( ReL-.r-
Mailing Address: 114t044 ZY& Jam'
City/State/Zip: J$zo?
Phone #:
E-mail: SEISCf/1��5Jii0ee11E,ek.1t)AU1Nt)l1Cf 0 4A&A1L_ CoIM,
STATE UBI #: FiCJ�I "�}351C,
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I M (CCB) & EXPIRATION DATE:
C A'.A�I I uI
Office Pic Only
TYPE OF
Accessory Structure/
Detached Garage
Details
Addition
L_jDemolition
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 profit for the work indicated on this application.
Valuation:
PROPOSED NEW SQUARE•• • •• THIS APPLICATION
Basement sq ft: Finished❑ Unfinished❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: If of NEW Bathrooms:
PROJECTDESCRIPTION
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: o
I
Signature: Date Q