ESLHA Permit ApplicationCity of Edmonds
DEVELOPMENT SERVICES
ESLHA BUILDING PERMIT
APPLICATION FORM F
12151h Avenue N, Edmonds, WA 98020
Phone 425.771.0220
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
1�;Z 1 S-n4 s-r sw •--rbr\okP(95 0)4
950zb
1`tZT y r- 19ssIFP��
Subdivision/Lot #:
Project Valuation: $
2 001000
APPLICANT:
Phone:
Fax:
US11 MO NTIquvc) N2►q PgghrETu-rzAaF- i i?,S1C3 Q
zOb -'5W2 -313Li
Address (Street, City, State, Zip):
E-Mail Address:
2307_0V0matJ0s
L.j sta K (9 H 2 t) 09126t`hrr-b7C,'Tr _ Coat
PROPERTY OWNER:
Phone:
Fax:
SN HIcON L'n-MS-:e;N
> 25-3H61-14S)
Address (Street, City, State, Zip):
E-Mail Address:
g832- IM(WIp I b� ' MUKl1_T D w� °l�z� S
s�I�rnoN• �I�1�5 � F)20011�EW .Cz�"
CONTRACTOR:*
Phone:
Fax:
oWNf V Aa IAS
Address (Street, City, State, Zip):
Contractor License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to doing work in the
City of Edmonds Business License #/Exp. Date:
City. Contact the City Clerk's Office at 425.775.2525
DETAIL SCOPE OF WORK: EXi5n Lyj Sf i4 • ryvft f LC�r� Iz c71 1 Ll s 5 i y b 4 S t=
MR) N fLOOif hyb Inor3 • q 0 H 3- Sr -04WR-Ei-1F
afloo narJ - 162► 1 .SF
Ut-Pf ft OOt2 ic)VO)F3DPJ C�-b Si= 0F,L)c_
ii'ypIT70r-�-
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: sq. ft C 1✓k 15TrN
Select Basement Type: j Finishe j Unfinished
1" Floor: bN sq. ft
Garage/Carport: ':�(ay -- sq .ft
2"d Floor: sq. ft. p Zl . I
Deck/Patio: b sq. ft
Retaining Wail: TYes No
Other: sq .ft
I declare under penalty of perjury laws 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: Sharon Larsen
Towner jAgent/Other(specify):Owner
Z�V1m
May 29, 2020
Signature: Sharon Larsen (May 29, 202014:20 PDT)
Date:
Updated: 12/2017 Packet Item #4