BLD2023-0750+OLD SCHOOL APP+6.14.2023_11.45.27_AM+3608953For handouts, submittal %
To apply for permits,
go to: www.mvbuild,
BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 Sth Ave N / Edmonds, WA 98020
425.771.0220
ements go to: www.edmondswa.gov.
inspections, or check application status
JOB SITE INFORMATION LOCATION: (Where the work is taking place)
Job Site Address: 21 10 76th Ave. West, Edmonds
Parcel
Lot /Unit/Suite #: Subdivision: WIIlnWcialP
BUSINESS OR PROPER OWNER: Gardens Div. 1
Name: Nova Family Resource & Childcare Center
Mailing Address: 21910 76th Avenue West
City/state/zip: Edm nds, WA 98026
Phone #: 425-214- 493 Carole Harper)
Email: caroleh@n vafam. org
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 safe, leas , rent, or exchange according to RCW
18.27.090.
Owner Signature:
APPLICANT / CONTACT NFORMATION:
Name of Applicant: Carole Harper
Mailing Address: 213110 76th Avenue West
City/State/Zip: Edm nds, WA 98026
Phone #: 425-214-�493
E-mail: caroleh@rhovafam.org
GENERAL CONTRACTOR (If different from applicant)
General Contractor: of yet identified
Mailing Address: Will urnish before permit issued
City/State/Zip:
Phone #:
E-mail
STATE UBI #:
CITY OF EDMONDS B SINESS LICENSE #:
WA STATE CONTRA OR L & I #: (CCB) & EXPIRATION DATE:
Office Use Only
TYPE OF PERMIT (Provide
Accessory Structure/
Detached Garage
Details on Page 2)
Addition
Demolition
O 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: $30,000
i
PROPOSED NEW SQUARE
Basement scl ft:
FOOTAGE FOR THIS APPLICATION
Finished Unfinished ❑
1st Floor, scl ft:
Existing, no new
2nd Floor, sgft:
Existing, no new
Garage/Carport:, scl ft:
Deck/Covered Porch/Patio:
# of NEW Bedrooms: N/A
PROJECT
# of NEW Bathrooms: N/A
Upper floor remains same use as professional
offices, no change.
Lower floor only 721 sf gross area to be changed
to be used as childcare from professional offices,
eexosting restroorn per code and provide exit sig '
s.
and egress illumination directional signs per plan.
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: Carole Harper
Signature: Date
06-15-2023
Occupancy Group(s): B
Occupant Load(s): 25
Type(s) of Construction:
V Fire Sprinklers: Yes11 No Z
WA STATE ENERGY COME
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, inechanical,
fire sprinkler, and/or fire alarm
permits are applied for
separately.
TI / CHANGE OF USE / NEW
BLDG: Include TRAFFIC IMPACT worksheet
A/C Unit /Compressor
Air Handler /VAV
GAS/FUEL CONNECTION COUNTS (flew, Relocated -fly` re piped) --
BTUs �
Qty BTUs Qty
A/C Unit
Outdoor BBC / Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
Other:
MEDICAL GAS, AIR VACUUM COUNTS
IT COUNTS (New and Relocated)
(New, Relocated or re piped)
"W"TUs Gas Elec Other Qty Qty Qty
Boiler
Dryer Duct
Exhaust Fans 50 cfm Restroom 1
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide elev -
tions if a Commercial Bldg)
Other:
Qty
Qty
Clothes Washer
Tub/ Showers
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
Drinking Fountain
1
Pressure Reduction/ Regulator Valve
Floor Drain/Sink
Refrigerator Water Supply
Hose Bibs
Water Heater - Tankless? Y or N
Hydronic Heat
Water Service Line
Sinks
;
Other:
Toilets
Other:
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum
Other:
DFMOLITIC
Type of structure to be demolished: None
Square footage of structure to be demolished: Nome
AHERA Survey done? Y[J/ NE PSCAA Case #: N/A
Critical Areas Determination: N/A
Study Required r � Conditional Waiver ❑ WaiverTANK
Fill in Place El Fill Material: N/A
Removal Size of Tank (Gallons)
Critical Areas Determination:
Study Required Conditional Waiver Waiver
•.D
Grading: Cut cubic yards N/A
Fill cubic yards N/A
Cut / Fill in Critical Area: Yes ElNo R1
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.