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1. Hitchens Permit Application (2)0V Int),11r, 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, AOU's, New Commercial, and Major Tenant improvement application submittals. If plans are prepared by a profession- al, electronic files are requested in addition to the hard copies. Please bring electronic files on a flash drive or coordinate for electronic transfer. Please caN 425-772-0220 to schedulean intake appointment) JOB SITE INFORMATION/LOCATION: (Where the work is taking place) Job Site Address: 12Q D 1 VISTA prL MAILIkkilS Parcel: D091"00001100 Lot /Unit/Suite #: It Subdivision: PROPERTY OWNER: Name: wpR \16aftEh6 MallingAddress: 33gp 17u' AIL I,M- City/State/zip: TmF1,XV0E LA A g8ov5' Phone #: 425— g4-I - 6309 Email: 1C00% OWNER INSTALLATION: •If yes, read and sign' Will work be performed by the property owner? ❑ Yes O 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: 1ZV&k% o"KA -I Mailing Address: (OL"m ogR.P1A BON44_gg&b City/State/Zip: 1�ISi0 V)I% 8D21. Phone#: E-mail: 12N�Aas�l11:M£s • Car+ GENERAL CONTRACTOR: (If different from applicant) General Contractor Mailing Address: Att"-14 City/State/Zip: L%)Pk Oft2to Phone If: q-T5 -4713 4.38� E-mail: R 4�KGalYi�ul{ 10MaS •t'Jr-- STATE UBI #: la2 - 02.3 - 3(.2- CITY OF EDMONDS BUSINESS LICENSE #: O I WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE: 0 DetailsTYPE OF PERMIT (Provide ❑ Accessory Structure/ Addition Detached Garage 'Demalitfan jdMechanical Mew Single Family / DuPlem- VPlumbing ❑ Fire Sprinkler ❑ Remodel ❑ New Comrnercial/ Mixed Use ❑ Re -Roof ❑Signs ❑ Tank OTenant improvement Q 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: 12S10oo Bncm,=..r sq it: rinished :W Unfinished J9 1 LOWsq# s 1 (fv 85 Garage/Carpere. sq­ft: I ts03 Deck/Covered P r- '- ER' Lotu—�P,,a.�iyto Other sq ft: (,aYf�)'. aqp l � 37 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: • IL4Date AL 7a'� GENERAL Occupancy Group(s): COMMERCIAL 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 UghVA& You rnLoa 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 JNevv and Relocarted)l BTUs Gas / Elec / Other City A/C Unit/Compressor _y/h - Air HandlerAW (/ V A G / aederkazitue q IcLi EIFGc72 tc / Dryer Duct 5 Exhaust Pans !L 8 Fireplace SDaoo 2 Furnace Heat Pump Unit 60 oCC Nm% Hydronic Heating teasc / Roof Top Unit (Provide eleva- tions if a Commercial Bldg) Other: PLUMBING FIXTURE COUNTS City (New, Relocated or re -piped) City Clothes W asFrer / Tub/ Showers Dishwasher Backli Device (RPBA, DCDA, AVS) / Drinking Fountain Pressure Reduction/ Regulator Valve / Floor Drain/Sink , Refrigerator Water Supply Z Hose Bibs 3 Water Heater-Tankless3®or N / Hydronic Heat / Water Service Line / Sinks L Other: 5/ / Toilets ¢ Other: BTUs City BTUs City A/C Unit am / Outdoor BBQ / Fire pit Boiler Stove/Range/Oven Dryer r•ar / Water Heater Fireplace/Insert 2 -- Other: '.Y�_ _ ml 1_ Furnace I I I Other Carbon Dioxide XIANitrous Oxide Ix Helium Oxygen Medical Air Other: Medical -Surgical Vacuum Other: I Type of structure to be demolished: Square footage of structure to be demolished: 017 AHERA n_..o.0 eicTfYi e44-a i—. I PSCAA Case N: Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑ Fill in Place ❑ FIII Material � WA7vOLOAL Removal ❑ Size of Tank (Gallons) Critical Areas Determination: Study Required ❑ Conditional Waiver ❑ Waiver ❑ Grading: Cut q O cubic yards Fill LoO cubic yards Cut / Fill in Critical Area: Yes ❑ Nov� 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.