BLD2021-0850+APPLICATION+6.17.2021_3.33.58_PM+2256751100
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.gov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildingpermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 21909 96th Ave W Edmonds, WA
Parcel: 00373600700901
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: William Hecox (Tenant: T-Mobile)
Mailing Address:
21909 96th Ave W
City/State/Zip: Edmonds, WA 98020
Phone #:
Email
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? Yes �✓ 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 exchange according to RCW
18.27.090.
Owner Signature: N/A
APPLICANT / CONTACT INFORMATION:
Name of Applicant: T-Mobile, by Ryka Consulting
Mailing Address: 5628 Airport Way South, Ste 330
City/State/Zip: Seattle, WA 98108
Phone #: 206-523-1941
E-mail: ccontreras@rykaconsulting.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: Ericsson Inc
Mailing Address:6300 Legacy Drive
City/State/Zip: Plano, TX 75024
Phone #: 972-583-1388
E-mail
STATE UBI #: 601 377 400
CITY OF EDMONDS BUSINESS LICENSE #: TBD
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
ERICSI*909LH\ 12/13/2022
Office Use Only
TYPE OF PERMIT (Provide
❑ Accessory Structure/
Detached Garage
Details on Page 2)
Addition
❑
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 for the work indicated on this application.
Valuation: 10,000
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement scl ft: Finished❑ Unfinished ❑
1st Floor, scl ft:
N/A
2nd Floor, scl ft:
N/A
Garage/Carport:, scl ft:
N/A
Deck/Covered Porch/Patio:
N/A
# of NEW Bedrooms: N/A # of NEW Bathrooms: N/A
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: Christine Contreras
Signature: Date 6/17/20
Occupancy Group(s): U
COMMERCIALGENERAL
Occupant Load(s):
Type(s) of Construction: 11B
Fire Sprinklers: Yes❑ Noa
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
NSA
N/A
N/A
Air Handler /VAV
N/A
N/A
N/A
Boiler
N/A
N/A
N/A
Dryer Duct
N/A
N/A
N/A
Exhaust Fans
N/A
N/A
N/A
Fireplace
N/A
N/A
N/A
Furnace
N/A
N/A
N/A
Heat Pump Unit
N/A
N/A
N/A
Hydronic Heating
N/A
N/A
N/A
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
' V
Other:
N/A
N/A
N/A
FIXTURE
Qty
COUNTSPLUMBING
Qty
Clothes Washer
0
Tub/ Showers
0
Dishwasher
0
Backflow Device (RPBA, DCDA, AVB)
0
Drinking Fountain
0
Pressure Reduction/ Regulator Valve
0
Floor Drain/Sink
0
Refrigerator Water Supply
0
Hose Bibs
0
Water Heater - Tankless? Y or N
0
Hydronic Heat
0
Water Service Line
0
Sinks
0
Other:
0
Toilets
0
Other:
0
COUNTSGAS/FUIEL CONNECTION d or re piped)
BTUs Qty BTUs Qty
A/C Unit
N/A
o Outdoor BBQ/ Fire pit
N/A
o
Boiler
N/A
o Stove/Range/Oven
N/A
o
Dryer
N/A
o Water Heater
N/A
o
Fireplace/ Insert
N/A
o Other:
N/A
o
Furnace
N/A
o Other:
N/A
o
COUNTSMEDICAL GAS, AIR VACUUM
Relocated or re piped)
Qty Qty
Carbon Dioxide
N/A
I Nitrous Oxide
N/A
Helium
N/A
Oxygen
N/A
Medical Air
N/A
Other:
N/A
Medical - Surgical Vacuum
N/A
Other:
N/A
DEMOLITION
Type of structure to be demolished: N/A
Square footage of structure to be demolished: N/A
AHERA Survey done? Y❑/ N❑
PSCAA Case #: N/A
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver❑
Fill in Place ❑ Fill Material: N/A
Removal ❑
Size of Tank (Gallons) N/A
Critical Areas Determination:
Study Required Conditional Waiver Waiver
GRADE/FILL/EXCAVATE
Grading: Cut N/A cubic yards
Fill N/A 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.