BLD2021-0408+City Application+3.19.2021_2.11.48_PM+2102261"nC. I g9Ij
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswa.aov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildinapermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 65 N Zlfi)& & ,SW•
Parcel: 005M0000000
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER: Name: _ DOIV l ��O G l)Gi R KnJ Mi,l1-
Mailing Address: 2,15 41 St. SW.
City/State/Zip: Wmnrdfi w1. aMfo2)
Phone #: 425 A W - "611a
Email: 12, U10ae �GI/)0 fll1V)( Ci'l�L{. Oi'Yl
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ Yes EfNo
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: U� I.ClvLa ff Ich
Mailing Address: 129-11 V'W AY-b W A205
City/State/Zip: L V-Pi' , IALA.
Phone#: 4f95- qyL- F1t20
E-mail: 21s P+.Il (nr6Tand SUM
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: Mriham,fta6t Al MA.t.I
Mailing Address: 152 0 151 St AT cSVU
City/State/Zip: LidrivivyWil IAJ A. 0 k0 $1
Phone #:20(.9--7ctq - qQ(k
E-mail: WhIl mi al[uaW(G1W 7 204-a l.Pl'9m
STATE UBI #: C12 D 3 52) q43
CITY OF EDMONDS BUSINESS LICENSER:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
MASPE S * SS32.DF : 0 &eL
Office Use Only
TYPE OF
Details
Accessory Structure/
Detached
Addition
Garage
Demolition
Mechanical
❑ New Single Family/Duplex
❑ Plumbing
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 fothe work indicated on this application.
Valuation: C2 ,CVQ
Basement sq ft: Finishedl I Unfinished
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: i # of NEW Bathrooms:
Li 1111 M L' " M
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:
Signature:
Date
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
cl0CF1
uclmiG
I
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE d 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:
CONNECTION COUNTSd or re piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
5c6i ZOO
I
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
Other:
COUNTSMEDICAL GAS, AIR VACUUM
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? YQ/ N[]
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
GRADE/FILL/EXCAVATE
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.