City Application�A OF ED& � BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
!qe )8qo 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.mvbuildinapermit.com
JOB SITE INFORMATION/LOCATION: (Where the �wos�rk Is taking place)
Job Site Address�tC�():y.�
Parcel:
Lot/Unit/Suite q: Subdivision:
BUSINESS OR PROPERTY OWNER
Name: FZIY`Cl�il w�
^Q
Mailing Address:
City/State/Zip: ��,a��'1•����Y—S Q�
Phone fl: -.eawb " —R
OWNER INSTALLATION: -lives, read and sign*
Will work be performed by the property owner?yes OrNo
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:
APPLICANT/ CONTACT INFORMATION:
Name of Applicant: �f�-j4=l'—W,
Mailing Address: 155
City/State/Zip'r IHiii`��,.,�' Q��'iWT-PI
Phone d:
E-mail:
GENERAL CONTRACTOR:: (if different from appli nt)
General Contractor: Y`M.IY��.�
Mailing Address:y--i� � 4t%L�r
City/State/Zip:
v"..d waridn,
Phone t : 'L6tQ� I/�1 A t$+
E-mail:
STATE UBI Jt: IO_D •lrTrJ� ,1
CITY OF EDMONDS BUSINESS LICENSE q: .�.JiUMQi
WA STATE CONTRACTOR L & I M (CCB) & EXPIRATION DATE:
Permit tt:
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:
FOOTAGEPROPOSED NEW SQUARE •• THIS APPLICATION
Basement sq it: Finished ElUnfinished
it:
it:
rt:, sq ft:
LNEWBedrooms:
d Porch/PEf
rooms:s:
PROJECT DESCRIPTION
CI � iil
is
I certify that the in rmation l 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.
Wtu1
Print Name: ,1^ �nt11
Signa Z Dat Isa W
GENERAL COMMERCIAL DATA
0
Occupancy Group(s): !I Occupant Load(s):
Type(s)of Construction: �' Fire Sprinklers: Yes.2 No[:]
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 Relocited)
BTUs Gas/Elec/ Other MY
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Hearing
Rooftop Unit (Provide eleva-
tions if. a Commercial BILg)
OtherPLUMBING FIXTURE COUNTS (New, Relocated or re piped)
Qty Utv
r
s Washer Tub/Showers
asher ' Backflow Device(RPBA, DCDA, AVB(
ng Fountain Pressure Reduction/ Regulator Valve
Drain/Sink Refrigerator Water Supply
Bibs Water Heater - Tankless?YorN
Hydronic Heat Water Service Line
Sinks Other:
Toilets Other:
BTUs Qty
A/C Unit Outdoor BBQ/Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/Insert Other:
Furnace I I I Other:
BTUs City
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other -
Medical - Surgical Vacuum
Other:
Type of structure to be demolished:
Square footage of structure tobedemolished:
AHERA Survey done? Y❑/N❑ PSCAA Case M:
Critical Areas Determination:
Study Required❑ Conditional Waiver❑ Waiver❑
Fill in Place ❑ Fill Material:
RemovalSize of Tank(Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
Grading: Cut cubic yards
Fill cubic yards
I 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.