BLD2024-0360+OLD SCHOOL APPLICATION+3.14.2024_7.47.32_AM+4130157BUILDING PERMIT
APPLICATION
Development services
Building Division
121 5th Ave N / Edmonds5 8020
�� 0220
For handouts, submittal requirements go to: www edmondswa.aov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildinaaermit.com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 105 5th Ave S
Parcel: 004342120000102
Lot /Unit/Suite #: _.—
Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: Jonathan Mayo
Mailing Address: 8451 SE 68th St----
city/state/Zip: Mercer Island, WA 98040
Phone #:
Email:
OWNER INSTALLATION: "If yes, read and sign'
Yes No
Will work be performed by the property owner?❑
I own, reside in, or will reside ino hercompleted
t I own wh c res nolt
installation is being made on p p Y that
intended for sale, lease, rent, or exchange according to RCW
18.27.090.
Owner Signature:
APPLICANT / CONTACT INFORMATION:
Name of Applicant: Shari Rust
Mailing Address: 4549 125th Ave SE
city/state/zip: Bellevue, WA 98006
Phone #: 206-406-3437
Email: shari@newimagecreative.com
GENERAL CONTRACTOR: (If different from applicant)
General contractor: New Image Creative Sign Inc.
4549 125th Ave SE
Mailing Address:
Bellevue, WA 98006
City/State/Zip:
Phone #: 206-406-3437
Email: shari@newimagecreative.corn
STATE UBI #: 602-339-833
CITY OF EDMONDS BUSINESS LICENSE #: 602-339-833
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
NEWIIC961 B9 03/22/2026
Office use Only
I certify information I have provided on this form/application is true,
correct and complete, and that I am the property owner or duly authorized
_..,..,« nf tha orooerty owner to submit a permit application to the City of
Date
03/14/2024