BLD2021-0171+City Application+1.29.2021_12.26.26_PM+2021220100
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.mybuildingpermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 19726 88TH AVE W
Parcel: 00549300000400
Lot /Unit/Suite #: 9 Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: CORY AND LISA JOHNSON
Mailing Address:
19726 88TH AVE W
City/state/zip: EDMONDS, WA 98026
Phone #: 360-751-2470
Email: CORYPJOHNSON@GMAIL.COM
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:
Mailing Address: 23020 EDMONDS WAY, #113
City/state/zip: EDMONDS, WA 98020
Phone #: 206-542-3734
E-mail: HEIDI@H2DARCHITECTS.COM
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:_
City/State/Zip:
Phone #:
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Office Use Only
TYPE OF PERMIT (Provide
Accessory Structure/
Detached Garage
Details on Page 2)
J 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: $200,000
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement scl ft: Finished Unfinished ❑
1st Floor, scl ft:
760.1 (BSMT)
2nd Floor, sclft:
166.3 (MAIN FLR)
Garage/Carport:, scl ft:
597.5
Deck/Covered Porch/Patio:
452.6
# of NEW Bedrooms: 2 # of NEW Bathrooms: 0
PROJECT•
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: Cory Johnson
Coto, 7o6thtoe 1 /25/202
Signature: CoryJo nson(J- 25,20210435 PST) Date
COMMERCIALGENERAL
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
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
Refrigerator Water Supply
Hose Bibs
Water Heater - Tankless? Y or N
y
Hydronic Heat
Water Service Line
Sinks
Other:
Toilets
Other:
COUNTSGAS/FUIEL CONNECTION d or re piped)
BTUs Qty BTUs Qty
A/C Unit
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
19900-199900
1
Fireplace/ Insert
Other:
Furnace
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: EX ATTACHED GARAGE
Square footage of structure to be demolished: 494.7
AHERA Survey done? Y❑/ N❑✓
PSCAA Case #:
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver0
Fill in Place ❑ Fill Material:
Removal ❑
Size of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
GRADE/FILL/EXCAVATE
Grading: Cut 50 cubic yards
Fill 15 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.
City -Perm it_Appl ication_M BP
Final Audit Report 2021-01-25
Created:
2021-01-25
By:
Heidi Helgeson (heidi@h2darchitects.com)
Status:
Signed
Transaction ID:
CBJCHBCAABAAWxOJcpTHNMmensnzxOcCnEHrhg9vKZKP
"City_Permit_Application_MBP" History
Document created by Heidi Helgeson (heidi@h2darchitects.com)
2021-01-25 - 3:32:38 AM GMT- IP address: 180.176.23.230
Document emailed to lisajohnson1122@gmail.com for signature
2021-01-25 - 3:34:22 AM GMT
Email viewed by lisajohnson1122@gmail.com
2021-01-25 - 4:06:56 AM GMT- IP address: 66.249.84.215
Heidi Helgeson (heidi@h2darchitects.com) replaced signer lisajohnson1122@gmail.com with Cory Johnson
(corypjohnson@gmail.com)
2021-01-25 - 4:19:29 AM GMT- IP address: 180.176.23.230
Document emailed to Cory Johnson (corypjohnson@gmail.com) for signature
2021-01-25 - 4:19:29 AM GMT
Email viewed by Cory Johnson (corypjohnson@gmail.com)
2021-01-25 - 12:29:45 PM GMT- IP address: 66.249.84.209
&Q Document e-signed by Cory Johnson (corypjohnson@gmail.com)
Signature Date: 2021-01-25 - 12:35:04 PM GMT - Time Source: server- IP address: 24.19.177.239
Q Agreement completed.
2021-01-25 - 12:35:04 PM GMT
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