BLD2020-0581+City_Application+8.3.2020_6.45.27_PMoV EDMO BUILDING PERMIT
�: do 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: http://www.edmondswa.gov/
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: (j'*d ALD-2, 5'('
Parcel: O64'b 42bg 400 qao
Lot /Unit/Suite #: g Subdivision: F LIG, 0 {4--
PROPERTY OWNER: 1
Name:�)Urf i�C-r M UY
Mailing Address: 00 Al DF V—
City/State/Zip: t P , I tow
Phone#: Q2,r1' 7?j
10-407
Email: ShlvgLt471(v6 Q) h0iG6'1h1^
OWNER INSTALLATION: *If yes, read and sign*
Will work be performed by the property owner? ❑ Yes WNo
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: KK151W MOD N
Mailing Address: Oil A[.Um ZT'
City/State/zip: r—D M ON D5 19 o1,y
Phone #: _415 • 1-14 • —712q
E-mail: I�av��onL�.2LvIRV� IYliu(• tU W1
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:_
City/State/Zip:
Phone #:
E-mail:
WA STATE CONTRACTOR L & I # (CCB) & EXPIRATION DATE:
CITY OF EDMONDS BUSINESS LICENSE #:
Office Use Only
(ProvideTYPE OF PERMIT
❑ Accessory Structure/
Detached Garage
Details ..
&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:
PROPOSED NEW SQUARE FOOTAGE FOR THIS APPLICATION
Basement sq ft: Finished Id Unfinished ❑
1st Floor, sq ft:
+ r
2nd Floor, sq ft:
•�'
Garage/Carport:, sq ft:
►^
Deck/Covered Porch/Patio:
...
Other sq ft:
PROJECT•
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• L A-MV— FAIL D R.ao 1= i V LN`f Q
' MIAOVE Ex. sutipwM ILO x 101
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: l ;J�IN tK, v
Signature: � /1M� V1 Date T'%'2�•�
GENERAL COMMERCIAL DATA
Occupancy Group(s): K•-�7 Occupant Load(s): ,-✓
Type(s) of Construction: V� Fire Sprinklers: Yes El No 2
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
MECHANICAL EQUIPMENT COUNTS (New and Relocated)
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:
PLUMBING FIXTURE COUNTS (New, Relocated or re -piped)
City 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
Hydronic Heat Water Service Line
Sinks 2 Other:
Toilets ` Other:
BTUs City BTUs City
A/C Unit Outdoor BBQ/ Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/Insert Other:
Furnace I I I Other:
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum
Other:
Type of structure to be demolished: S V W. K V Q M
t
Square footage of structure to be demolished: `(go
AHERA Survey done? V / N PSCAA Case #:
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material:
Removal El Size of Tank (Gallons
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Grading:Cut �%+u• 40 cubic yards
Fill 49- cubic yards ,-,/
Cut / Fill in Critical Area: Yes ❑ No
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.