BLD2020-0893+City_Application+8.25.2020_10.12.15_AMBUILDING PERMIT
APPLICATION
Development Services
Building Division
121 5th Ave N / Edmonds, WA 98020
`'I t gym 42 ).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: 21022 74th Ave W, Edmonds Wa, 98026
Parcel: 00566900400201
Lot /Unit/Suite #: Subdivision:
PROPERTY OWNER:
Name: David Harris
Mailing Address: 19702 20th Ave NW
City/State/zip: Shoreline/Wa/98177
Phone #: 2065465392
Email: harris.davidm@hotmail.com
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 / CONTACT INFORMATION:
Name of Applicant: Same as owner
Mailing Address:
City/State/Zip:
Phone #:
E-mail:
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:
Office Use Only
TYPE OF PERMIT (Provide Details on Page 2)
❑ 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,
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:
1080
2nd Floor, sq ft:
1818
Garage/Carport:, sq ft:
760
Deck/Covered Porch/Patio:
20
Other sq ft:
PROJECT•
Removal of existing house on site and installation
of a new duplex, with associated driveway, walks,
and patios with drainage improvements.
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: DA'VID µ, HAMS
Signature: Date _7 W12VW
GENERAL• DATA
Occupancy Group(s): Occupant Load(s):
Type(s) of Construction: Duplex Fire Sprinklers: Yes ❑ No ❑
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
Boiler
Dryer Duct
5
Exhaust Fans �,�<L4 l ��
Fireplace
Furnace
y,31.v x a.
Heat Pump Unit qf1', A40 E ���{ r%L a
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
COUNTSPLUMBING FIXTURE
Qty Qty
Clothes Washer Tub/ Showers Lj
Dishwasher Backflow Device (RPBA, DCDA, AVB) r
Drinking Fountain Pressure Reduction/ Regulator Valve
Floor Drain/Sink Refrigerator Water Supply
Hose Bibs L( Water Heater -Tankless? Y or N
Hydronic Heat Water Service Line I
Sinks () Other:
Toilets (j Other:
CONNECTION COUNTS- • or re -piped)
BTUs Qty BTUs Qty
A/C Unit Outdoor BBQ/ Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert Other:
Furnace Other:
MEDICAL GAS, AIR VACUUM COUNTS
(New, Relocated or re -piped)
Qty Qty
Carbon Dioxide Nitrous Oxide
Helium Oxygen
Medical Air Other:
Medical - Surgical Vacuum Other:
DEMOLITION
/—
Type of structure to be demolished: el, le —
Square footage of structure to be demolished:
AHERA Survey done0 Y /I N PSCAA Case h:
Critical Areas Determina'tion:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
Fill in Place ❑ Fill Material:
Removal ❑ Size of Tank (Gallons)
Critical Areas Determination:
Study Required ❑ Conditional Waiver ❑ Waiver ❑
.,D
Grading: Cut cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No ❑
GENERAL• •
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.