FIR2020-0096+City_Application+11.4.2020_3.16.25_PMRECEIVED
BUILDING PERMIT Office
Nov 04 2020
. CITYOFEDMONDS APPLICATION Permit#: FIR2020-0096
DEVELOPMENT SERVICES
DEPARTMENT Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to: www.edmondswa.gov.
PLEASE NOTE: Intake appointments are required for New Single Family
Residences, Large Additions, ADU's, New Commercial, and Major Tenant
Improvement application submittals. If plans are prepared by a profession-
al, electronic files are requested in addition to the hard copies. Please bring
electronic files on a flash drive or coordinate for electronic transfer.
Please call425-771-0120 to schedule an intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 30-0 Avt< S .
Parcel: 2703 23v�4oSNt�O
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: 15EQE54VA0 BobTH PLA.(-
Mailing Address: 1+11 311p 4yt: S • STS ZL9q
City/State/Zip: kpy-%ypj s wA W
Phone #: �•iZS� -i-]i, ylc�t7
Email:
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ Yes B 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: 3 4 )4 111tt
Mailing Address: PO 130x 3i11
City/State/zip: AAU1Jt:?0w4 WA 911223
Phone #: NZIT 7*114 Itiq<
E-mail: —St1Gt 4P, SW Jy f1lLE • GtAw%
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: T3 & m Ftjw
Mailing Address: p0 13OX 3-111
City/State/Zip: (4fZ1_IW&'T&J WA gys?_3
Phone #: Lftg ZR4 IL 45'
E-mail: 3'E.¢Y�- aNN>rtt2£-CoY-�
STATE UBI #: IoO3 &17— 117,
CITY OF EDMONDS BUSINESS LICENSE #: ire f OA AG V•
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
314 f 1 A44 r. SLI <ll to/ 2Z
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 the work indicated on this application.
Valuation: 13, Soc�
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT•
N S i rAL.Lya L.y&!7Tj_ l Ah0IW 66A/3l t
1t)R6 ALA " 3457SY" Fug E.A9&4
DG?�?1vN AmO 0U—%RAw _'V Ak9jF xana
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 ::re Ff%fulwep
Signature: Date �_�
COMMERCIALGENERAL 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 permit uire
associated plumbing, mechanical, fire sprinkler, a /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
Exhaust Fans
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE .. .. .
Qty Qty
Clothes Washer
Tub/ Showers
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Re erator Water Supply
Hose Bibs
Water Hea r - Tankless? Y or N
Hydronic Heat
Water Service Lin
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
7
Dryer
Wa Heater
Fireplace/ Insert
Other:
Furnace Other:
COUNTSMEDICAL GAS, AIR VACUUM
Relocatedor ..•.
Qty
Qty
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
er:
Medical - Surgical Vacuum Other:
DEMOLITION
Type of structure to be demolished:
Square footage of structure demolished:
AHERA Survey done? Y / N
PSCA se #1:
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ aiver ❑
Fill in Place ❑ F' terial:
Removal ❑
of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ iver ❑
.•
Grading: Cut cubic yards
Fill cu ards
Cut / Fill in Critical Area: Yes ❑ N
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.