City applicationBUILDING PERMIT
APPLICATION
Development Services
Building Division
11" "o
, r
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to, htto://www.edmondswa.aov/
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 22050 99th PL W Edmonds,WA 98020
Parcel: 0nRrl91 nQ1 QQ7flrl
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: Matthew Hart
Mailing Address: 22050 99th PL W
City/State/Zip: Edmonds, WA 98020
Phone #: 206-979-4315
Email: matthewhart@gmail.com
OWNER INSTALLATION: *If yes, read and sign"
WIII work be performed by the property owner? ❑ Yes IXNo
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: Tom Ayres
Mailing Address: PQ Box 31228
City/State/Zip: Seattle, WA 98103
Phone #: - 47
E-mail:
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address: PO BOX 31228
City/State/Zip: Seattle WA 98103
Phone #: 206-547-8347
E-mail: onto filcoenviro.com
WA STATE CONTRACTOR L & I # (CCB) & EXPIRATION DATE:
FILCOCIO80RU 12/31/2021
CITY OF EDMONDS BUSINESS LICENSE M N R-0241 11
Permit #:
❑ Accessory Structure/ ❑ Addition
Detached Garage
❑ Demolition ((Mechanical
❑ New Single Family / Duplex ❑ Plumbing
❑ Fire Sprinkler
❑ Remodel
❑ New Commercial/ Mixed Use I ❑ Re -Roof
❑ Signs
X 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 protft for the worklndicated on Ihts opplfcafiion.
Valuation:
Basement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
Pump out triple rinse and excavate and remove j
one 300 residential heatina oil tank. i
Haul Tank away and properly dispose,
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
I Edmonds.
Print Name: Melirpa Hess
r �./ 6/28/2021
1 Signature: _Date
Occupancy Group(s): Occupant Load(s):
BTUs Qty BTUs City
Type(s) of Construction: Fire Sprinklers: Yes ❑ No ❑
A/C Unit Outdoor BBQ/ Fire pit
WA STATE ENERGY CODE: If your project affects the building envelope,
Boiler Stove/Range/Oven
mechanical systems, and/or lighting, you must complete the
T
appropriate WSEC forms.
_ _
DEFERRED SUBMITTALS: All commercial building permits that will require
Dryer
Y Water Heater
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
Fireplace/ Insert Other:
TI / CHANGE OF USE / NEW BLDG: Include TRAFFIC IMPACT worksheet
Furnace Other:
EQUIPMENTMECHANICAL COUNTSMEDICALCOUNTS
Relocated or re -piped)
BTUs Gas / Elec / Other City
Qty qty
A/C Unit /Compressor
Carbon Dioxide Nitrous Oxide
`—
Helium Oxygen
Air Handler /VAV
Medical Air Other:
Boiler
Medical - Surgical Vacuum Other:
Dryer Duct
Exhaust Fans
DEMOLITION
Type of structure to be demolished:
Fireplace
Square footage of structure to be demolished:
Furnace
Heat Pump Unit
AHERA Survey done? Y / N PSCAA Cas e lf:
Critical Areas Determination:
Hydronic Heating
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Roof Top Unit (Provide eleva-
tions If a Commercial Bldg)
Other:
Fill in Place ❑ Fill Material:
�f
Removal KI Size of Tank (Gallons) 300
COUNTSPLUMBING FIXTURE Relocated or re -piped)
Critical Areas Determination:
I
Qty
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Qty
Clothes Washer Tub/ Showers
•A•EXCAVATE
Dishwasher Backflow Device (RPBA, DCDA, AVB)
Grading: Cut _ cubic yards
_
Fill yards
Drinking Fountain Pressure Reduction/ Regulator Valve
_cubic
Cut / Fill in Critical Area: Yes El No El
Floor Drain/Sink Refrigerator Water Supply
Hose Bibs Water Heater - Tankless? Y or N
GENERAL PROVISIONS
APPLICATIONS: Applications are valid for a maximum of 1 year.
Hydronic Heat Water Service Line
ESLHA Applications, 2 years.
Sinks Other;
LICENSING: All contractors and subcontractors are required to be licensed
_
with Washington State Department of Labor & Industries and have a
Toilets Other:
current City of Edmonds Business License.