Mitchell Building Permit Application,nC. t 8N-
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 48020
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.mybuildingpermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
.Job Site Address: 20029 Maplewood Dr
Parcel:
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: Chris Mitchell
Mailing Address:
20029 Maplewood Dr
City/State/Zip: Edmonds, WA 98026
Phone #: 425.778.4337
Email: mitchell.thehammer@gmail.com
OWNER INSTALLATION: *if yes, read and sign"
Will work be performed by the property owner?F]Yes R] 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
1&27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: Four Day Fireplace LLC
Mailing Address: 3923 88th St NE Suite A
City/State/Zip: Marysville, WA 98270
Phone #: 425.512.1671
E-mail: sales@fourdayfireplace.com
j GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:_
City/State/Zip:
Phone #:
E-mail:
STATE Ual #t 604060866
CITY OF EDMONDS 01?SrINEU LICENSE Mi ##NIA-027110
WA STATE CONTRACTOR I. & I W. (CCEi) & EXPIRATION DATE.
FOUROD1=8358J 1/1412023
TYPE OF PERMIT (Provide Details on Page 2) Structure/ Addition
Detached Garage El
ODemolition
❑ Mechanical
New Single Family/Duplex
Plumbing
Fire Sprinkler
® Remodel
New Commercial/Mixed Use
❑ Re -Roof
Signs
❑ Tank
^----__�--
ElTenant 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 tar the work indicated on this application.
Valuation: 20,000
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement scq ft: Finished Unfinished
1st Floor, sq ft.
0
2nd Floor, sq ft:
0
Garage/Carport:, sq ft:
0
Deck/Covered Porch/Patio:
0
# of NEW Bedrooms:0 # of NEW Bathrooms:0
PROJECT•
�c.n new �if� �T�rn Me+c,� lti
l ^line
I n 11 j M. f2�n^urc
/
�rr�V. Ch Mnx I^iI./d L"nviry C 6()
I cerer"fy that the information I have provided on this formlapplication is true,
correct and complete, and that I am the property owner or duly authorized
agent of the property owner to submit a permit appliratbri tb the city of
gdmomda.
Pr(nt Nalme: �IRI G SIgALi
Signature: Date Z 0-51,2I
COMMERCIALGENERAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction:
Fire Sprinklers: YesElNoFl
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 i and Relocated)
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
51000
Gas
1
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
Backf ow Device (RPBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
Water Heater - Tankless? Y of N
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
CONNECTION COUNTSd or re piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
51,000
1
Other:
Furnace Other:
MEDICAL GAS, AIR VACUUM COUNTS
Relocated 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: Chimney
Square footage of structure to be demolished: 2QSF
AHERA Survey done? Y❑/ NF'l
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 Waiver
..
Grading: Cut cubic yards
r
' Fill cubic yards
Cut / Fill in Critical Area: Yes L___J No El
GENERALPROVISIONS
APPLICATIONS: Applications are valid for a maximurri of 1 year.
ESLHA Applications, 3 years:
LICENSING: All contractors and subc€rntrictors are required to bw licensed
with Washington state Department of Gabor & Industries and have a
current City of Edmonds Business License.