bldg permit appEB O BUILDING PERMIT
�-L
APPLICATION
Permil�:
beyeilijJment Sefyices
I3Wding Wvis3crtt
121 Sth Ave Al / Edmonds, WA 9$i?2ii
-
fn� 425.771.0220
p Accessory Structure/
tl�For
handouts, submittal requirements, permitsiatus and ins
q Inspection
Addthon
Detached Garage
scheduling information go to: www.edmondswa.eov: .
i�i i dSE iYf3iE Intake appointments are required for New Single Family
❑ Demolition ❑ Mechanical
Residences, Large Additions, ADLI's, New Commercial, and Major Tenant
Improvement application submitfals..if plans are prepared by a profession-
❑ New Single.Family J Duplex ❑ Plumbing -
at, electronic files are requested in addition to the hard copies. Please bring
electronic files on a flash drive or coordinate for electronic transfer.
❑Fire Sprihkler t] Remodel
Please aril 425-77I-az2o to sdredale an b take appolobnest-1
JOB SITE 9WOMMM NILOCATION: (Where the work is taking plac$1
Job Site Address: _ I. l 3 , i2 E i'(P✓
Parcel: 7 Q� 70 i
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER {
Name: �'1 iG4Y B.I k {�' PVi _ � lnAA 4et i �.{ iA�i en
Mailing Address: It 141. (D, AtifC ra
City/State/Zip:
Phone#C�
Emailr��l�i%i�y�tly r Lt7
)iillNER INSTALLAIWN: *if yes, read and sign*
Will -work be performed by the property owner? II Yes KNo
i own, reside in, or will reside in the completed cture. This
installation is being made on prope at I ich is not
intended for sale, lease, rding to RCW
18.27.090.. .
Owner Signature
1PPLICANT./ COIYTAtri IN ORMA71 .
Name of Applicant b P.ft'G
Mailing Address: 21-
'City/Statoziip �s 'n s� 4a r�+� ia�^� , w A.
Phone
E-mail: M i k i t Gib �b� C J'rs'1
ENERAL CONTRACTO& (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:
❑' New'Cominen:iai/ Mixed Use 'FK(Re-Roof
O Signs O1 Tank
Q Tenant Improvement ❑ Other
Iter nectel Ptarrr* fefs are based on .'
The value of the work performed. Indicate the value (rounded to
the nearest doh) of all equipment, materials, "labor, overhead,.,
and the profit for the work indicated on this application.
�re - rlt9Cr�
FROM
Basement sq ft. FmishedX Unfinished II
1st Floor, sq ft.
2nd Floor, sgft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
AC7b1'r-1 1 e,9F
_. D,J sw-S
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. ! t�
Prim Name: IUk i ,Irt1'11J
Signature: k _Date -i`
GENERAL COMMERCIAL
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 • and Relocated)
BTUs Gas / Elec i Other Qty
A/C Unit /Compressor
0
Air Handler /VAV
0
Boiler
0
Dryer Duct
Exhaust Fans
Fireplace
Gas
1
Furnace
Gas
1
Heat Pump Unit
0
Hydronic Heating
0
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
0
Other:
COUNTSPLUMYING FIXTURE . • or • .-.
Qty Ctty
Clothes Washer
1
Tub/ Showers
3
Dishwasher
Backfiow Device (RPBA, DCDA, AVB)
1
Drinking Fountain
0
Pressure Reduction/ Regulator Valve
1
Floor Drain/Sink
Refrigerator Water Supply
1
Hose Bibs
4
Water Heater -Tankless? Y or N
n
Hydronic Heat
Water Service Line
Sinks
4
Other:
Toilets
4
Other:
GAS/FUEL CONNECTION COUNTS (Nev,, 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.
COUNTSMEDICAL GAS, AIR VACUUM
(New, Relocatedor 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:
Required ❑ Conditional Waiver ❑ Waiver ❑
imii
Fill in Place ❑ Fill Material:
Removal 0
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•
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.