permit application copy (2)°C. 18y"
BUILDING PERMIT Office Use Only
APPLICATION Permit #:
Development Services
Building Division
121 51h Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements, permit status and inspection
scheduling Information go to: www.edmondswa.gov.
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 call425-771-0220 to schedule an Intake appointment!
JOB SITE INFORMATION/LOCATION: (Where the work Is taking place)
Job Site Address: l Oeeo a5: "n 1VL W
Parcel:
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name:
Mailing Address: ,, !'I,
City/State/Zip: ��Mo Y js i wil,\ -�z(
Phone#: 425�SC�5��3
Email: rj,�,QeurdeGC@C.�fYKC�St
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 no
intended for sale, lease exchange a Ing to
18,27.090.
Owner Signature:
APPLICANT / CONTAP INFORMATION:
Name of Applicant: ` n !
Mailing Address: y��C `\�� //{Q vv
City/State/Zip: VyV)P�"J �" V `U020
Phone #: `� "SV20
E-mail: �.�t'� ��U � �moS�' vie
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:-
City/State/Zip:
Phone #:
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
DetailsTYPE Of PERMIT (Provide
❑ Accessory Structure/
❑ Addition
Detached Garage
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,
;nd the profit for the work indicated on this application.
i
Valuation:
Im
ZH9Z=A1iF 1�IC1Ar cni iAor [nnTAr-r rnO THIC appI lr fTIr1N-I
I Easement sq ft: Finished ❑ Unfinished ❑
1st Floor, sq ft:
in f
2nd Floor, sq ft:
Garage/Carport:, sq ft:
Deck/Covered Porch/Patio:
Other sq ft:
PROJECT DESCRIPTION
1� V�V 1 V W `I'li
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 duty authorized
agent of the property owner to submit a permit application to the City of
Edmonds. �O
Print Name::
SignatuDate 2
04
COMMERCIALGENERAL DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Fire Sprinklers: Yes ❑ N
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
EQUIPMENTMECHANICAL •
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor /�
Air Handler /VAV / / c,
V I
Boiler
Dryer Duct
Exhaust Fans
Fireplace 4
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE
QtY QtY
Clothes Washer ` TA Tub/Showers
Dishwasher Backfow Device (RPBA, DCDA, AVB)
Drinking Fountain Pressure Reduction/ Regulator Valve
Floor Drain/Sink Refrigerator Water Supply
Hose Bibs Water Heater-Tankless? Y or N
Lnic Heat Water Service Line
Other:s Other:
GAS/FUEL CONNECTION
BTUs
COUNTS (New, Relocated or re -piped)
Qty BTUs Qty
A/C Unit
VA/�
Outdoor BBQ/ Fire pit
Boiler
Stove/Range/Oven
Dryer
Water Heater
Fireplace/ Insert
Other:
Furnace
Other:
(New,
COUNTSMEDICAL GAS, AIR VACUUM
Relocated or ..•.
Qty
Qty
Carbon Dioxide
Nitrous Oxide
I
Helium
Oxygen
Medical Air
Other:
Medical - Surgical Vacuum Other:
DEMOLITION
( Typ^ of structure to be demolished: �cmvmm
IJ
Sq:, i e f:;-.t-ige of structure to be demolished: �5
v/ l
I�I AHERA Survey done? Y / N
l�—
FPC-ASA Case q:
Critical Areas Determination:
Study Require Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material: V-\�6�
Removal ❑ Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Grading: Cut h1�i1 cubic yards
Fill V\�Ol 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.