FG Site Development Permit Application•ne. I S4 ,
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: www.edmondswa.Qov.
PLEASE NOTE: Intake appointments are required for New Single Family
Residences, Large Additions, ADU'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 call 425-771-0210 to schedule an intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: A n, b+'A' 4,,:U F5 S
Parcel: OOg-�) 9"2_l 220 19OD
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: C-{ P_k S IP l C.1=F'P__1 NCB
Mailing Address: �t Q 4 MAP L5 S�
City/State/Zip: r,Ip M ON'DS wA ` ED20
Phone#: 2-0(c)-4 ` 1 2_�_3-
Email: r_T1!br_AA_a \•2.2.V\ 0—CSiV '
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 /ONCONT_ACT INFORMATION: G 15 AN
Name of Applicant:
bpi' m MULLW
Mailing Address:
7 ZVI GR-5W, �M) P AU N
City/State/Zip:
SEA_I' L'E t WA-1 $103
Phone #: ZO fo
" O Z — Z I
E-mail: aQbL
G �a — a-X" �• ��1i�
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
cltQ C O w STe—\)cV 1 ON
Mailing Address:
j! 04 MAP"i ST
City/State/Zip: �.��"�o1.i0S
wlk M0210
Phone #: ZD
CD — rAclii
E-mail:
Q-� 0A
STATE UBI #:
O
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
— l t1P O 055 t1C IV?_10 -•1_
Permit #,
TYPE OF ..
❑ Accessory Structure/ ❑ Addition
Detached Garaee
❑ Demolition
❑ Mechanical
❑ Plumbing
,New Single Family L3J
❑ Fire Sprinkler
❑ Remodel
❑ Re -Roof
❑ New Commercial/ Mixed Use
❑ 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 ❑ Unfinished ❑
1st Floor, sq ft:
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT DESCRIPTION
LI V l L 6J0 P_� Egf-I
2�
T l.1 N 5S
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•142$