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BLD2021-0867+APPLICATION+6.21.2021_3.34.35_PM+2261383BUILDING PERMIT APPLICATION Development Services Building Division 121 5th Ave N / Edmonds, WA 98020 425.771.0220 For handouts, submittal requirements, permit status and inspection scheduling information go to: www.edmondswa.gov. PLEASE NO 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 42-771-0220 to schedule an intake appointment! JOB SITE IN FORMATIONLLOCATION--LWhere-hereIs Job Site Site Address: D Ite 6*6 AV U t _ Parcel: 2� D32 4 DO ZZ'�i DO Lot /' ��'•,�41 _.Subdivision: DiANAr LI: F. PROPERTY OWNER: Name: A NOt Mailing Address 0'J2 Cr �v 4 City/State/Zip: V_DMD �J D5 11 oDZr—) Phone Email: MC i a ri ednedu OWNER INSTALLATION: *If yes, read and sign* Will work be performed by the property owner? ❑ Yes Ai 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: ICKI. 7[1Q KAN5ON _ Mailing Address: t0'2 Z A 1,D Sr- city/state/zip: M 45 W ►� g D Z.D Phone #: 4 • � 1 Z� E-mail: haytioy c e-3SyI i� �liK►ot i . Cmry GENERAL CONTRACTOR: (If different from applicant) General Contractor: 15VAP D V_NNr_1T1r Mailing Address: 00 0 U QqF_ W City/State/Zip: % 'I 1037 Phone #: e) "' 3 5Q E-mail: • 14g. OLb V v►Y1 let�lymca4 # •� STATE LIBI #: _ _ 0 2. 1 �� CITY OF EDMONDS BUSINESS LICENSEM WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE: 7F'-_r1W't #: . .. ....... . . .... TYPE OF ❑ Accessory Structure/ ❑ Addition Detached Garage © Demolition ❑ Mechanical ❑ New Single Family / Duplex ❑ Plumbing ❑ Fire Sprinkler ❑ Remodel New Commercial/ Mixed Use ❑ Re -Roof Signs ❑ Tank ❑ Tenant Improvement t� ' other G Remodel Permit lees are based on: The value of the work performed. indicate the value (rounded to the nearest dollar) of all equipment, motedals, labor, overhead, and the profit for the work indicated on this application. Valuation: PROPOSED NEW SQUARE FOOTAGE • • THIS APPLICATION Basement sq ft: Finished ❑ Unfinished ❑ 1st Floor, sq ft: 2nd Floor, sq ft: Garage/Carport:, sq ft: Deck/Covered Porch/Patio: V.5 3 1 e Other sq ft: PROJECTDESCRIPTION W 3h •fT u/ ors D 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. j��, t 1 1 4 t Print Name- ��i�``'Ft5T�1]&J CtAiJ`7ylnJ Signature: [ . V Llu ` Date GENERAL COMMERCIAL DATA Occupancy Group(s): I'v"`-2 Occupant Load(s): Type(s) of Construction: v v� Fire Sprinklers: Yes ❑ No ❑ WA STATE ENERGY CODE: If your project affects the b ild' g envelope, mechanical systems, and/or lighting, you must co este 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 MECHANICAL EQUIPMENT COUNTS (New and Relocated) BTUs Gas / Elec % Other 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) Qty Qty Clothes Washer Tub/ Showers Dishwasher Backflow Device(RPBA, DCDA, AVB) Drinking Fountain Pressure Reduction/ Regulator Valve Floor Drain/Sink • Refrigerator Water. Su ply Hose Bibs Water Heater T kle s? Y or N Hydronic Heat Water Service Line Sinks Other: Toilets Other:- - BTUs City BTUs City A/C Unit Outdoor BBQ/ Fire pit Boiler Stove/Range/Oven Dryer Water H r Fireplace/ Insert Other: I Furnace I I ( Other: Carbon Dioxide Nitrous Oxide Helium Oxygen Medical Air Other: Medical - Surgical Vacuum Other: Type of structure to be demolished: V ezor— Square footage of structure to be demolished: ?JZV r AHERA Survey done? Y /VN PSCAA Case #: Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver v. Fill in Place ❑ Fill Material: Removal ❑ Size of Tank (Gallons) Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑ Grading: Cut cubic yards Fill cubicy s 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.