CITY APPLICATIONOV EpAr
� O
Inc, t g90
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 Sth 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.mvbuildinaaermit.com
JOB SITE INFORMATION/LOCATION: (where the work is taking place)
Job Site Address: 515 Main Street
Parcel:
Lot /U n it/Su ite #: Subdivision,:
BUSINESS OR PROPERTY OWNER:
Name: Chris Fleck
Mailing Address:
City/State/Zip:
Phone #: 206-909-3910
I
1 Email:
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? yes �✓ No
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: Niko Raptis
Mailing Address: 515 Main Street
City/State/Zip: Edmonds, WA, 98020
Phone #: 206-778-4848
E-mail: theioft515m@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
DetailsTYPE Of PERMIT (Provide
Accessory Structure/
Bekeeheel Gepage — I5 N i Addition
Demolition
Mechanical
❑ New Single Family/Duplex
Plumbing
Fire Sprinkler
Remodel
New Commercial/Mixed Use
Re -Roof
❑ Signs
❑ Tank
Tenant Improvement
Other P6Q ii li
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: $2000
PROPOSED NEW SQUARE,a O.THISAPPLICATION
Basement sgft: Finished❑ Unfinished❑
1st Floor, sq ft:
2nd Floor, sqft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
PROJECT
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: Niko R
Signature: Date t t /12/2020
OccupancyGroup(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes❑ NOZ
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
BTUs Gas / Elec / Other Qty
A/C unit /Compressor
rFans
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
PLUMBING FIXTURE COUNTS
(New, d or re piped)
Qty
Qty
Clothes Washer
Tub/ Showers
Backflow Device (RPBA, DCDA, AVB)
Dishwasher
Pressure Reduction/ Regulator Valve
Drinking Fountain
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
Water Heater-Tankless? Y or N
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
BTUs My BTUs My
A/C Unit Outdoor BBQ/ Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert Other:
Furnace I I Other:
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical -Surgical Vacuum I I Other:
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 ❑ 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 ❑
APPLICATIONS: Applications are valid for a maximum of 1 year.
ESLHAApplications, 2 years.
LICENSING: All contractors and subcontractors are required to Jwith Washington State Department of Labor & Industries and h
current City of Edmonds Business License.