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City Application"? c• i ;c 9" BUILDING PERMIT APPLICATION Ir! x: Develgpment Services Building Division 121 5th Ave N / Edmonds, WA 98020 425.771.0220 For handouts, submittal requirements go to: www.edmondswogov. To apply for permits, schedule inspections, or check application status go to: www.LnAbuildingpermit.com JOB SITE INFORMATION/LOCATION: (Where the work is taking place) Job Site Address: ��i qo f h Au,', 1 Parcel: Lot /Unit/Suite#: l Subdivision: BUSINESS OR PROPERTY OWNER: Name: J/hMA � 1/1ar1,,VA a+, H Mailing Address: 0*117 &A City/state/4: f erh;4Vo5 IVA9 ie0140 Phone #: .)�-50 ) V - 2 217 Email: 1"7H � 14 yta/.},L . Lj7ti 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: �t Name of Applicant: J H J d6 Mailing Address: 1'�'61 7A /L City/State/Zip: ' /� 4 " �- Pq' A/A ldl!K Phone #: L2 W 3 (3 Z%i o5, - E-mail: fWr-L,ir"�����; IJ GENERAL CONTRACTOR: (If different from applicant) General Contractor: Irl' %�• ��/Y �n� Mailing Address: 3 City/State/Zip: AY- Phone #: J E-mail: +Jnld Y M*A,'✓`%"all STATE UBI #: "t—V11-L IL, L° W (� CITY OF EDMONDS BUSINESS LICENSE #: WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE: _i ua 1n TYPE OF Accessory Structure/ Detached Garage .. Addition Demolition ❑ Mechanical ❑ New Single Family/Duplex Plumbing Fire Sprinkler Remodel ❑ New Commercial/Mixed Use ❑ Re -Roof Tank ❑ Signs ❑ 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. 4'jo f, PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION Basement sq ft: Finished❑ Unfinished 15t Floor, sq ft: 33 7 6•/ 2nd Floor, sq ft: Garage/Carport:, sq ft: Deck/Covered Porch/Patio: # of NEW Bedrooms: i # of NEW Bathrooms: PROJECT DESCRIPTION 3_37s� M 4,,j ��r�- I cemfy 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: James Leach and Dionna Leach Signature: GENERAL COMMERCIAL DATA Occupancy Group(s): Occupant Load(s): Type(s) of Construction: Fire Sprinklers: Yes ElNo IL 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 MECHANICAL EQUIPMENT COUNTS (New and Relocated) BTUs Gas /Elec/Other City A/C Unit /Compressor Air Handler /VAV Boiler Dryer Duct 3e� Exhaust Fans " e, s}H��M Fireplace Furnace Heat Pump Unit Hydronic Heating Roof Top Unit (Provide eleva- tions if a Commercial Bldg) Other: PLUMBING FIXTURE COUNTS (New, Relocated or re piped) City City Clothes Washer Tub/ Showers Dishwasher E Backfiow Device (RPBA, DCDA, AVB) Drinking Fountain Pressure Reduction/ Regulator Valve Floor Drain/Sink Refrigerator Water Supply Hose Bibs Water Heater-Tankless?&r N Hydronic Heat Water Service Line Sinks Other: Toilets / Other: BTUs City BTUs Qty A/C Unit Outdoor BBQ/ Fire pit Boiler Stove/Range/Oven Dryer Water Heater I Fireplace/Insert Other: I Furnace I I I Other: Carbon Dioxide Nitrous Oxide Helium Oxygen Medical Air Other: Medical -Surgical Vacuum Other. Type of structure to be demolished: Square footage of structure to be demolished: AHERA Survey done? Y❑/ N❑ PSCAA Case g: 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 I cubic yards Fill cubicyards Cut / Fill in Critical Area: Yes 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.