8427BuildingPermitAppBUILDING 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.eov.
PLEASE NOTE: 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 call425-771-0220 to schedule an intake appointment!
JOB SITE INFORMATION/LOCATION: (Where he work is taking place)
Job Site Address: '42'7 Za2'�" S', 5u�,.
Parcel: 2-7o-( I goc>20-) O O
Lot /Unit/Suite #: "3 /A Subdivision: k31A
PROPERTY OWNER:
Name: MA(2-� 0—,a
Mailing Address: PD
City/State/Zip: t'Z P- -1 t ozo
Phone#: 'L{2S - Z4 2-- /09 oU
� a1
Email: F�f I-& 1p C 7 &h'iA1 L • l d%
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? L>� Yes C 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 exch rding to RCW
18.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: f`4WPkz- CUo
Mailing Address: FO —F.)',-F.)o X k Q 25 p,Q
City/State/Zip: 'Ed n
D✓►\J IDS � A - -! p 020
Phone #: Z� q Z2 • CO 00
E-mail: EA-F �� 7 C�1'1'1Ai L UM
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
(ProvideTYPE OF PERMIT Details ..
C Accessory Structure/ ❑ Addition
Detached Garage
❑ Demolition
❑ Mechanical
New Single Family / Duplex
❑ Plumbing
C Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use
❑ Re -Roof
❑ Signs
❑ Tenant Improvement
❑ Tank
❑ 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 for the work indicated on this application.
Valuation:
PROPOSED NEW SQUARE
Basement sq ft: Nik
FOOTAGE FOR THIS APPLICATION
Finished ❑ Unfinished ❑
i 1st Floor, sq ft:
16i
i 2nd Floor, sgft:
Z3 �Z
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT
DESCRIPTION
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 1���'7-0
GENERAL COMMERCIAL DATA
Occupancy-Group(s): Occupant Loatl(s):
Type(s) of C - onstructiom. Fire Sprinklers: Yes 11 No 11
-WAnATE ENERGY CODE: -if.�our-proi*ect-affLictt�the:bulldlng*-envelopt,:
rnechanical.systems�.afnd/o.r I.ighting,.you. must complete the
appropriate*WSEC forms.
OEFERRED -SUBMITTALS:: All com nercial building oermits*that will require
associated plumbing*,* me c**1hanicaIj*1ine* sprinklerand/or-fite alarm
permits.. are a pplied for separately.
-Ti CHANGE OF USE /*NEW BLDG4 IncludeTRAFN - C IMPACT Workihe6t
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
BTLIS Gas] diec/ Other Pty.
A/C U nit /to rn pressoi r
Air Handler JVAV
Boiler
DrVer*Duc
ExhaustFans
FireplaO
Furnace
11710. A
6AS
Hea.t.0ump.Unit
aec
Hydronic. Heating.
Roof Top Unit (Provide eleva-
tions if a Commercial Elldg)
Other:
P L U M B I N G F I XT U R E C 0 U NTS (N ew, Relocated. or re -piped)
Qty QtY
Clothes Washer
Tub/ Showers
Dishwasher
Backflow Device (RIPBA, bCbA, AVB)
Drinking Fountain
Pressure Reduction/ RegulatorValve
Floor-Drafri/Strik
Refrigerator Water-.51upply
Hose Bibs
-Water Heater - tankless? N
Hydronic Heat
Water -Service Line
Sinks-
Other;
Toilets
Cither.
NECTION COUNTS (Neik, Re e-d I:!:". -
GAS/FUEL C'ON'
BTUs BTUs Qty
A/C Unit
Outdoor BBQ re.pit
Boiler
Stove/Rangeloven.
D*ryer
.1
Water* Heater
F ireplace/ Insert
Other:
Furnace
other:
MEDICAL GAS� AIKVACUUKCOLINTS�
My My
.Carb on:Dioxi.de
Nitrous Oxide
.Helium
Oxygen
Medical Air.
Other.,
Medical - Surgii
EMOLITION�:
Type -of structureto- be demolished.
Squa N? footage of-structu re to be -demolished:.
AHER.A..Survey-done? Y/N.
PStA Case.#:
Critical Areas Dete0miriation,
.. Study Required 13 Waiver*--[] Waiver 0
Fill in Place 11 fill Material.,
Removal 0
Size of Tank (Gallons)
Critical Areas Determination:
Study,RequJred13 Conditional Waiver El Waiver El
GRADE/F1ILL/EXCAVAT-E-`%
Grading: Cut cubic yards
Fill* —cubicyards
Cut/ Fill !n*CritIcaIAr0a:* Yest] NO)V
GENERAL- PROVISIONS.
APPLICATIONS: A*00lications:are -valid for a maximurn-of-I year*.
ESLHA ANlication.% 1years..
LICENSING: All coritractors.and subcorittactori are� �eqUlred to be licensed
with Washing . on -State Department -of Labor & Industries and* have a
current City *of Edmonds Bus iness License..
I i