1. Hitchens Permit Application°� E f''''o BUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling information go to:
PLEASE NOTE: Intake appointments are required for New Single Family
Residences, Large Additions, ADU's, New Commercial, and Major Tenant
Improvement application submittals. It plans are prepared by a profession-
al, electronic files are requested in addition to the hard copies. Please bring
electronic tiles on a flash drive or coordinate for electronic transfer.
Please call 425-771-0220 to schedule an intake appointment!
10B SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: I'1go 1 iill Ism MPde; j110
Parcel: 0 091 +1-0 1") 001100
Lot /Unit/Suite #: -11 _ Subdivision:
PROPERTY OWNER:
Name: 6—Aill � LlW(LJ-\
Mailing Address: 338C) 121�'} A�1�- AZ
City/State/Zip: '-EL.L"EV00 WN 9f V05j
Phone #: ¢257- !94-1 - 15,30157
Email: !t-FA1Cp✓+-
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:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: fZ0311t �(
Mailing Address: FQYH Ps
City/State/Zip: m►iL1► be'_ wix q$D?J'
Phone#: 4-27 -+7$-&38o
E-mail: �lY�-+ip/v\�li • C�►`r"
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address: �6(031
City/State/Zip:
Phone #: �5 -Ir7g -G38�
E-mail: GL�K�ctl���/%OMeS
STATE UBI #:3�ez-
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & Q(PIRATION DATE:
Accessory Structure/ I ❑ Addition
Detached Garage
(Demolition
W Mechanical
*ew Single Family f4)4ialeit-- I V Plumbing
❑ Fire Sprinkler ❑ Remodel
❑ New Commercial/ Mixed Use I ❑ Re -Roof
❑ Signs
❑ Tank
I
❑ Tenant Improvement ❑ Other
I
Remodel Permit fees are based on:
Tne value of the •work performed. Indicate the value (rounded to
the nearest dollar) of all equipment, materials. labor. overhead,
and the profit the work indicated on this application.
Valuation:
B&&Qa = jq ft: Finished �6 Unfinished
L19tOWIrA -24 00 854
k' Z.b4-'S
Garage/Cac#e�sq-ft: g03
Inp.rµ Ftoo �5��o
Deck/Covered P
Other sq ft:
bli;Erno�11
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:
Signature: Date AL Zoe
Occupancy Group(s):
COMMERCIALGENERAL DATA
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 fighting, you unust 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
_ A7A
Air Handler AMT "V
A
C
aerwH
R i%J
Dryer Duct
'S eoo
S
Exhaust FansIMaw
L
S
Fireplace
rjp�p�
2
Furnace
Heat Pump Unit
OTC
rJ
Hydronic Heating
0 oo�
i
C
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
FIXTURE
Qty
.. ..•.
COUNTSPLUMBING
QtY
Clothes'JJasher
Sub/ ihoweTS
!�
Dishwasher
Backflow Device (RPBA, DCDA, AVB)
/
Drinking Fountain
Pressure Reduction/ Regulator Valve
r
Floor Drain/Sink
Refrigerator Water Supply
Z
Hose Bibs
?�
Water Heater-Tankless?®or N
/
Hydronic Heat
/
Water Service Line
/
Sinks
L
Other: St,
rTollets
¢
Other.
CONNECTION
COUNTS..
.. .
BTUs
Qty
BTUs
Qty
A/C Unit
,
Outdoor BBQ/ Fire pit
&Own
/
vw
Boiler
Stove/Range/Oven
gp'a o
Dryer
Water Heater
�s�deo
row
Fireplace/ InsertgqqJL
2
Other:
Z
Furnace
Other:
(New,
GA5,_
Relocated
AIR VACUUM
COUNTSMEDICAL
or re -piped)
QtY
Qty
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical'
Other:
DEMOLITION
Type of structure to be demolished:
Square footage of structure to be demolished: =Q -7
v . I
AHERA Survev done?Uf N I PSCAA Case q:
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material: WAND,„) AL
Removal ❑ I Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Grading: Cut +22 cubic yards
Fill Lv0 cubic yards
Cut / Fill in Critical Area: Yes ❑ Noo
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.