BLD2020-0878+City_Application+8.20.2020_2.25.11_PM`nc. I0.9"
BUILDING PERMIT office use Only
APPLICATION Permit #:
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmandswa.gov.
To apply far 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: 22u z o Hwi- sq Jror &4/ys " 98aZ(,
Parcel: 270Y290030-3 Tao
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: 4 5"A/MWO00 l 0-6 A
Mailing Address: P o.Box 11"17
City/State/Zip: EOM0,00S 1A" y907_0
Phone #: y2,5. 221 - 1600
Email: Q-Ad-lsaa (,� f4,tAwoo d ho4 j a - tam
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? Dyes 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: 8>ZLAN SRO-sNlifV
Mailing Address: 2710 16Y rN 57- G7_ S .
City/State/Zip: IAIeC4000 k/ 4 99'yq"
Phone#: 25.1 'i95' 70'?! 11 I!
E-mail: 6brasoa„ e4 be— .I�+ n Y�cye s con
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: 146A7fi R/oe.71lwEs7'
Mailing Address: 2710 Iov714 S7- Cll s.
City/State/Zip: I-AK464060p WA 51eY9,1
Phone#: 253. 7o-i1
E-mail: 6hPari7annv I�Uti ndr ules�-earn
STATE UBI #: 60211?5 5'`/9
CITY OF EDMONDS BUSINESS LICENSE #: AIR - o z 66fi0
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
R4.47HNT9#I3L 3/30/2a2 Z
TYPE OF
❑ Accessory Structure/
Detached Garage
..
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 fhe work indicated on this application.
Valuation: 2500. 00
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sgft: Finished❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: # of NEW Bathrooms:
PROJECTDESCRIPTION
Q�l►ta+rE E�rST�it/G s7G�1 Foa?/tiG �-,vD
lN6'741-t_ IUEcW pI f A/GN —1LL1,_oin. *760
F12.EE.S7A,v011VG- S /G fv Wt 7iq "f w j=0071,V(r
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: OR iA V pRos,vf.y
Signature: Date $ ?e Zoe
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
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Exhaust Fans
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)
QtY City
Clothes Washer
Tub/ Showers
Dishwasher
BackFlow Device (REBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
Water Heater - Tankless? Y or N
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
GAS/FUEL CONNECTION COUNTS (New, Relocated or re piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
Other:
MEDICAL
GAS,
AIR VACUUM COUNTS
(New,
Relocated
or re piped)
City
City
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 q:
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 cubic yards
Fill 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.