BLD2020-1388+City_Application+12.21.2020_3.54.30_PM+1958338'nc. W)"
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswo.gov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildinaaermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 740 - 14th Way
Parcel: 390100001300
Lot /Unit/Suite #:1,Q Subdivision: RFL AIRF DIV C
BUSINESS OR PROPERTY OWNER:
Name: David Ito
Mailing Address: 740 -14th Way
City/State/Zip: Edmonds WA 98020
Phone #: 206-909-4204
Email: mrdavidito@gmail.com
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. ; l (�
Owner Signature: �- :�..�---
APPLICANT / CONTACT INFORMATION:
Name of Applicant: Al Cohen, Architect
Mailing Address: 330 Dayton St #6
City/State/Zip: Edmonds WA 98020
Phone #: 425-776-7373
E-mail: alcohendesign@gmail.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:_
City/State/Zip:
Phone #:
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Office Use Only
TYPE OF PERMIT (Provide
Accessory Structure/
Detached Garage
Details on ..
Addition
Demolition
Mechanical
New Single Family/Duplex
Plumbing
Fire Sprinkler
Remodel
New Commercial/Mixed Use
Re -Roof
Signs
❑ Tank
❑ Tenant Improvement
❑ Other
I
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: 11,250
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished❑ Unfinished❑
1st Floor, scl ft:
232
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms:0 # of NEW Bathrooms:0
PROJECT•
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I
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nsu'ate and finish existing non -heated space
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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: Albert Cohen
Signature:AL6&ate 12/21 /20
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: 500w Elect wall htr 1
COUNTSPLUMBING FIXTURE or re piped)
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/FLIEL CONNECTION COUNTS (New, Relocated or re piped)
BTUs Qty BTUs Qty
A/C Unit Outdoor BBQ/ Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert Other:
Furnace Other:
MEDICAL•
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 ❑ TS7,ize of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
.D
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.