BLD2023-0518+PAPER APPLICATION+4.26.2023_8.52.05_AM+3505987BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N j Edmunds, WA 48020
425*771-0220
For h andouts, sub mittai requirements go to: ww ..dmon ds wa..go .
To apply o r p er its, schedule i nspec Hons, o r ch eck app}i ca tion status
J 0 B SITE I N F 0 III ATI 0 I /LOCATION: (W here the work is taking place)
Joky Site I
Parcel:
Lot Unit cite#: Subdivision; alt W ac A6
BUSINESS OR PROPERTY OWNER:
Name. -
City/5tz
Phone r
Email:
G, Z t� Z2't
OWNER INSTALLATION: *If yes, read and sign*
M l I work be performed by the property owners [:]Yes No
I own., reside in, or will reside in the completed structure. This
installation is being made on property that I own which i's not
intended for sale, lease, rent, or exchange according to RCW
18.27.090,
Owner Signature:
APPLICANT j CONTACT INFORMATION:
Name of Applicant:
aiIinAddress: 3 r
City/State/Zip: �
Phone #:
E-mail:
Iql-I)VIap-at; WA O�aal
7TO e
GENERAL CONTRACTOR: (If dif#9r" nt from applicant)
-a
General oIntract r.-
ailinddr*es:
City/State/Zip:
Phone #: InI
E-mail:
STATE U B I ##:
CITY OF EDMONDS BUSINESS LICENSE #: I��.�
4101n
WA STATE C
ONTRACTOR L & I : (CCR) EXPIRATION DATE:
t��Vk4 SI�[a3 F,riv�
L
F ,rmit =--
TYPE OF PERMIT
r
the nearest dollcr) of all equipment, materials, labor, overheod,
and the profit for the work indicated an this application.
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e
Valuation:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished Unfinished
1st Floor, sq ft: (D
rid Floor, sq ft-,
Garage/Carport:, sq ft:
Dec k/Covered Parch P ati D:
f NEW Bedrooms: # of NEW Bathrooms;
PROJECT DESCRIPTION
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Ifl LA I C U Out ely(olvol IQ� it i,lol I11 Yi
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1 ce r tify th at the i nfo rmabon I have p rovided on t h is fo rm/a p p licati on is truer
I correct and complete, and that I am the property owner or duly authorized
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agent of the property owner to subm it a permit application to the City of
Edmonds.
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i Print Name: ktA
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Signature: All Date
. V
Occupancy Group(s):
Type(s) of Construction.
■
o,nCoo
Occupant Load(s):
Fire 5prin1tlers: Yes No�
WA STATE ENERGY CODE: If your project affects the building envelope,
mechanical. systems, and/or lighting, you rust Complete the
appropriate WSEC forms.
DEFERRED SIB B I ITTAL : All ca immercia I bui Idi rig permits t hat wil I requite
associated plumbing, mechanical, fire sprinkler, and/or fire alarm
permits are applied for separately.
TI / CHANGE OF U5E / NEW flLQG; Include TRAFFIC IMPACT worksheet
ABC Unit /Compressor
Air Handler /VAV
Boiler
Dryer Duct
Eha ut Fans
Fire piae
Furnace
Heat Pump Unit
Hydronic Heating
Ptoof Top Unit (Provide eleva-
tions it a Commerclal Bldg)
Other,
BTUs Gas / Dec / ether 4ty
Qty t
Clothes Washer I I Tub/ Showers
Dishwasher
Backflow Device (RPBA, C?CDA, AVB)
Drinking Fountain I I Pressure Reduction/ Regulator Valve
Floor Drain/Sink I I Refrigerator Water Supply
H i I I Water Heater - Tan i s? Y or
Fiydranic Heat I I Water Service Line
Sinks I I Other;
BTUs QtVBTUs Qty
A Unit Outdoor BB Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert outer:
Furnace Other:
i i Al R
+
(New, Relocated or re p1ped)
Carbon Dioxide i Nitrous oxide
Helium I I Oxygen
Medical Air I I Other:
Medical - Surgical Vacuum I I Other:
Type of structure to be demolished:
Square footage of structure to be demolished:
AHERA Survey done? Y❑ / iV❑ I PSCAA Case #:
Critical Areas Determination:
r� iti r-rall ai r i t
Requiredstudy
Fill in Place 1:1
Removal ❑
Fill Material:
Critical Areas Determination-.
Study Required
Grading: Cut
Fill
Size of Tank (Gallons)
Conditional Waiver
er
cubic yards
cubic yards
Cut J Fill in Critical Area: Yes E h1a ❑
Waiver
APPLICATIONS: Applications are valid for a maximum of 1 year,
E LHA Appl r ations} 2 years.
LICENSING-. All contractors and subcontractors are required to be licensed
with Washington State Department of Labor & Industries and have a
u rrent City} of Edmonds Business License.
Toilets i I Other;