BLD2020-0626+City_Application+6.17.2020_2.18.48_PMBUILDING PERMIT
APPLICATION
Development Services
Building Division
121 Sth Ave N / Edmonds, WA 98020
' n c 10425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edmondswa.gov.
PLEASE NOTE: Intake appointments are required for New Single Family
Residences, Large Additions, ADU's, New Commercial, and Major Tenant
Improvement application submittals. If plans are prepared by a profession-
al, electronic files are requested in addition to the hard copies. Please bring
electronic files on a flash drive or coordinate for electronic transfer.
Please call 425-771-0220 to schedule an intake appointment?
JOB SITE I N FO RMATIONACICATION: (Where the work is taking place)
Job Site Address: 21601 76th Avenue West Edmonds. WA 99026
Parcel: 00580700002500
Lot /Unit/Suite M N/A Subdivision: N/A
PROPERTY OWNER:
Name: Public Hospital District #2 of Snohomish County
Mailing Address: 4710 196th St St
City/State/Zip: Lynnwood, WA 98036
Phone #: Not available
Email: Not available
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: T-Mobile c/o Technology Associates EC Inc.
Mailing Address: 9725 Third Avenue NE, Suite 410
City/State/Zip: Seattle, WA 98115
Phone #: (253) 682-8556
E-mail: meghan,howey@taec.net
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: To be determined at issuance
Mailing Address:
City/State/Zip: _
Phone M
E-mail:
STATE UBi #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #. (CCB) & EXPIRATION DATE:
Off c:e Use On.`
TYPE OF
.- Details
❑ Accessory Structure/
❑ Addition
Detached Garage
❑ Demolition
❑ Mechanical
❑ New Single Family / Duplex
❑ Plumbing
0 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: $25,000
Basement sq ft: N/A
Finished ❑ Unfinished ❑
1st Floor, sq ft:
N/A
2nd Floor, sq ft:
N/A
Garage/Carport:, sq ft:
N/A
Deck/Covered Porch/Patio:
N/A
Other sq ft:
N/A
T-Mobile proposes modifications to, an existing
telecommunication facility per plans. This project qualifies
as an ELIGIBLE FACILITY REQUEST under 6409.
I certify that the information I have provided on this form/application is true,
correct and complete, and that I am the property owneror duly authorized
agent of the property owner to submit a permit application to the City of
Edmonds.
Print Name: Meghan Howey
Date 6-17-2020
GENERAL COMMERCIAL DATA
Occupancy Group(s): U Occupant Load(s): Please reference
structural talcs
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 •
N/A BTUs Gas / Elec / Other 0 City
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:
PLUMBING FIXTURE COUNTS (New, Relocated or re -piped)
N/A Qty 0 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:
N/A BTUs Qty 0 BTUs City
A/C Unit Outdoor BBQ/ Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert Other:
I Furnace I I I Other:
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum
Other:
Type of structure to be demolished: N/A
Square footage of structure to be demolished:
AHERA Survey done? Y / N PSCAA Case k:
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material: N/A
Removal ❑ Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Grading: Cut 0 cubic yards
Fill 0 cubic yards
Cut / Fill in Critical Area: Yes ❑ No
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.