BLD2021-0190+City_Application+1.31.2021_6.47.40_PM+2025131AI40F EOtfO! BUILDING PERMIT
° APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
j?c. ►89� 425.771.0220
For handouts, submittal requirements go to: www.edmondswo.gov.
To apply forpermits, schedule inspections, or check application status
go to: www.mybuildinapermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 21302 93rd PI. W
Parcel; 00781600000100
Lot /Unit/Suite #: I Subdivision: Olymnir. Plate
BUSINESS OR PROPERTY OWNER:
Name: Karim Khoury
Mailing Address: 1113 Juniper Beach Road
city/state/zip: Camano Island, WA 98282
Phone #: 425-971-8614
Email: kkhoury@remax.net
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: Karim Khourj
Mailing Address: 1113 Juniper Beach Road
City/State/Zip: Camano Island, WA 98020
Phone #: 425-971-8614
E-mail: kkhoury@remax.net
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: McDonald & Co.
Mailing Address14909 16th St. SE
City/State/Zip: Snohomish, WA 98290
Phone #: 425-422-7237
E-mail: contact@mcdonaldremodels,com
STATE UBI #: 604-312-149
CITY OF EDMONDS BUSINESS LICENSE #: 604-312-149
WA STATE CONTRACTOR L & I M (CCB) & EXPIRATION DATE:
604-312-149 Exp. 1/10/2021
Office Use Only
OF PERMIT (Provide
❑Accessory Structure/
Detached Garage
DetailsTYPE
❑ Addition
Demolition
21 Mechanical
New Single Family/Duplex
Fv] Plumbing
Fire Sprinkler
21 Remodel
ElNew 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: 25,000
PROPOSED..
Basement sgft: Finished❑ Unfinished
1st Floor, sq ft:
2nd Floor, sgft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
PROJECT DESCRIPTION
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: Karim Khoury
SignaturE t� —� Date 1 /31 /21
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
BTUs Gas / Elec / Other QtY
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans TBD Elec
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
1
City MY
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 Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
TBD
1
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
GAS,
Other:
AIR VACUUM
COUNTSMEDICAL
(New,
Relocated
or re piped)
City
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 El 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 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.