BLD2020-1292_APPLICATION PG1_12-04-2020_10_36_56_Scan0002" C . 1 Z',,
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. ov.
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:
Parcel: U V o o o "oZ 00
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: % �/ j'�fil
Mailing Address: [ ,Ll `{i rCitlt✓
City/State/Zip:
Phone#: �f K 5t;3[
Email:
OWNER INSTALLATION: *if yes, read and sign*
Will work be performed by the property owner? ❑Yes ® 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: �JaA��I
APPLICANT / CONTACT INFORMATION:
Name of Applicant: A_A"`Ndlabie 1_114CAUVS LLIC
Mailing Address: ."� �1� d C
-..
City/State/Zip: — C'_Cl y"al a) ob,
Phone #:�
E-mail: daih'
GENERAL CONTRACTOR: (If different from applicant)
General Contractor: _ DO StQil- o ea 0?
Mailing Address:_,�1� Q�
City/State/Zip:
Phone #:
E-mail
STATE UBI #: l (% �� C 77 - , �-e
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & 1 M (CC$) & EXPIRATION DATE:
0Q
Office Use Only
TYPE OF PERMIT (Provide Details on Page 2)
❑Accessory Structure/ IkNAddition
Detached Garage
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.
I.
Valuation:'
PROPOSED NEW SQUAREas a APPLICATION
Basement sg ft: Finished Unfinished❑
1st Floor, sg ft:
'3 -7C1 �Y
2nd Floor, sgft:
G?�q�lfi1
Garage/Carport:, sg ft:
Deck/Covered Porch/Patio:
#of NEW Bedrooms: # of NEW Bathrooms:
"PROJECTDESCRIPTION
- •-�n vk_g bty—i
jI certify thatthe 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. Ay j
Print Name.• �� j
i Signature: ate i n
5
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