BLD2020-0965+City_Application+9.17.2020_2.02.58_PM`nc. 189'j
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.mvbuildingpermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 10729 226th ST SW
Parcel: 27032500310300
Lot /Unit/Suite #: 2 Subdivision: •1ohannpc;c;Pn
BUSINESS OR PROPERTY OWNER:
Name: Kari J. Johannessen
Mailing Address:
10727 226th ST SW
City/State/Zip: Edmonds, WA 9802
Phone #: (425) 830-1046
Email:
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? Yes V 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:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: Lee A. Michaelis, AICP
Mailing Address: 5005 200th St SW, Suite 101-B
City/State/Zip: Lynnwood, WA 98036
Phone #: (425) 830-1046
E-mail: lee.michaelis@pugetsoundplanning.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: Leif Helleren Construction, Inc
Mailing Address: P.O. Box 1764
City/State/Zip: Edmonds, WA 98020
Phone #: (206) 533-8200
E-mail
STATE UBI #: 601 818 421
CITY OF EDMONDS BUSINESS LICENSE #: 601818421
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
LEIFHC10380T 10/03/2021
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:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement scl ft: Finished❑ Unfinished ❑
1st Floor, scl ft:
2952
2nd Floor, scl ft:
1532
Garage/Carport:, scl ft:
982
Deck/Covered Porch/Patio:
552
# of NEW Bedrooms: 3 # of NEW Bathrooms:4
PROJECTDESCRIPTION
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: A. •cha is
Signature: 1 _ Date 09/17/20
GENERAL COMMERCIAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes❑ 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
EQUIPMENTMECHANICAL •
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Gas
1
Exhaust Fans
Elec
6
Fireplace
Gas
1
Furnace
Gas
1
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE or re piped)
Qty Qty
Clothes Washer
Tub/ Showers
4
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
2
Water Heater - Tankless? Y or N
Hydronic Heat
Water Service Line
Sinks
9
Other:
Toilets
4
Other:
CONNECTION COUNTSd or re piped)
BTUs Qty BTUs
Qty
A/C Unit
Outdoor BBQ/ Fire pit
1
Boiler
Stove/Range/Oven
1
Dryer
1 Water Heater
1
Fireplace/ Insert
1 Other:
Furnace
1 Other:
COUNTSMEDICAL GAS, AIR VACUUM
Relocated or re piped)
Qty Qty
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum
Other:
DEMOLITION
Type of structure to be demolished:
Square footage of structure to be demolished:
AHERA Survey done? Y❑ / N❑
PSCAA Case #:
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 200 cubic yards
Fill 200 cubic yards
Cut / Fill in Critical Area: Yes ❑ No W]
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.