BLD2020-0763+City_Application+7.27.2020_1.03.11_PMBUILDING PERMIT
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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 opplfcadon status
go to, www,mvbuildinavermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: _Ca8Z2 (�•'
Parcel- C204 13 C 02 (!!Ira O.t
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: C jjg:& L_ F.tQP A. M
Mailing Address: 18--12-t>
City/State/Zip: e)AlidM% (A -A 1&02k?
Phone #:
Email:
OWNER INSTALLATION: *If yes, read and sign*
sqi% aP J
Will be performed by the property owner? Ys � No
I own, reside in, or will reside in the completed structure. This
installation isfre-
g a an prop12: 1 a whit of
intended for eas re , or exchange arc rdir toll
18.27.090.
Owner Signa
APPLICANT
/ CONTACT INFORMATION:
,
Name of Applicant: � Wit.!
Mailing Address: _/_22 20E
City/State/Zip: irPMAl3Dri UJA #020
Phone #: '2Ola 0222,
jE-mail:
GENERAL CONTRACTOR: (if different from applicant)
General ContractorL.Acl,I, e
Mailing Address: 2Q_f ,
City/State/Zip: r:ORAOL)C 6 ldi6aZO
Phone #: iCl 82,b imu
E-mail:
STATE UBI #: Z'oQ A !2 S3[ 4
CITY OF EDMONDS BUSINESS LICENSE #: ; O Ii�23-E.
WA STATE CONTRACTOR L & i #: (CCB) & EXPIRATION DATE:
:—r-,t_A,itJAAA 251524S A-10. %021
Permit #:
TYPE OF PERMIT •. C
Accessory Structure/
Detached Garage
• g
Mr Addition
LLN
Demolition
O Mechanical
QNew Single Family/Duplex
Plumbing
U Fire Sprinkler
Q Remodel
ONew Commercial/Mixed Use
L J Re -Roof
Signs
❑ Tank
aTenant improvement
® Other
Remodel Permit fees are based on:
The value of the work performed. Indicate the value (rounded to
i the nearest dollar) of all equipment, materials, labor, overhead,
j and the profit fo the work indicated on this application.
� ,t
Valuation ,
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Flnished❑ Unfinished
1st Floor, sq ft:
t
2nd Floor, sq ft:
_..
Garage/empe#t, sq ft:
(�
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms: -49)-
PROJECT DESCRIPTION
a
r �gyerg f3C-W tOLMc e. CAMA yam_
1
k
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 erto submit a permit application to the City of
Edmonds.
( Print Name,
Occupancy Groupts):
Occupant Loa-
Type(s) of Construction:
Fir prinklers: Yesn No❑
WA STATE ENERGY CODE: If your ject affects the building envelope,
mechanical systems, and/o ighting, you must complete the
appropriate WSEC for .
DEFERRED SUBMtTT All commercial building permits that will require
associated plu ing, mechanical, fire sprinkler, and/or fire alarm
permits are plied for separately.
TI / CHANG F USE / NEW BLDG., include TRAFFIC IMPACT worksheet
MECHANICAL • • . -.
BTUs Gas J Elec / Other Qty
A/C Unit /Compressor
--
Air Handier/VAV
--
Boiler
---�
Dryer Duct
Exhaust Fans
Fireplace
--
Furnace
--+
Heat Pump Unit
---•
Hydronic Heating
----
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE . piped)
Qty QtY
Clothes Washer
Tub/Showers
Dishwasher
Backilow Device (RPBA, DCDA, AVB)
—,
Drinking Fountain
--
Pressure Reduction/ Regulator Valve
--,
GARA6iE
Poor. O- raiw/Sink
i
Refrigerator Water Supply
--
Hose Sibs
1
Water Heater-Tankless?Or N
Hydronic Heat
Water Service Line
--
Sinks
(
Other:
—^
loth
CONNECTION COUNTSRelocated or re pipe
BTUs Qty BTUs aty
A/C Unit
---
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
i
Water Heater
1
Fireplace/ Insert
Other:
Furnace Other: .r.
COUNTSMEDICAL GAS, AIR VACUUM
(New, Relocated or re piped)
Qty QtY
Caron Dioxide
---
Nitrous Oxide
�—
Helium
--
Oxygen
^
Medical Air
—^
Other:
�--
Medical - Surgical Vacuum —^ other: ^
DEMOLITION
Type of structure to be demolished: �X1S"R�St4 Cylc;taCt
Square footage of structure to be demolished:
AHERA Survey done? Y[]/ N❑
PSCAA Case #:
Critical Areas Determinatiioon;
Study Required l._I Conditional Waiver Waiver❑
Fill in Place ❑ Fill Materi
Removal ❑ Z
Size of Tank (Gallons)
Critical Areas ermination:
St y Required Conditional Waiver Waiver
..D
Grading: Cut < -. 5 D cubic yards
Fill < ftO cubic yards
Cut / Fill in Critical Area: Yes 11 No
GENERAL PROVISIONS
APPLICATIONS: Applications are valid for a maximum of 1 year.
ESLHA Applications, Z years.
LICENSING: All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & Industries and have a
rn irrPrit t'aty of Fdmonds Business License.