REVISED-Permit ApplicationBUILDING PERMIT
APPLICATION
Development Services
Building Division
121 Sth Ave N / Edmonds, WA 98020
425.771.0220
For handouts, submittal requirements go to: www.edmondswmaov.
To apply for permits, schedule inspections, or check application status
go to: www.mybuildinaoermir com
JOB SITE INFORMATION/LOCATION: (Where the work is taking place)
Job Site Address: 6907 160th ST
Parcel: 00513100003712
Lot /Unit/Suite #: Subdivision:
BUSINESS OR PROPERTY OWNER:
Name: 4UP WASH LLC
Mailing Address: PO Box 2517
City/State/Zip: Kirkland, WA 98083
Phone #: 206-619-4672
Email: donjury@jbires.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 jr CONTACT INFORMATION:
Name of Applicant: Don Jury
Mailing Address: PO Box2517
city/state/zip: Kirkland. WA 98083
Phone #: 206 619-4672
E-mail: donjury@jbires.com
GENERAL CONTRACTOR: (If different from applicant)
General Contractor:
Mailing Address:_
City/State/Zip:
Phone It:
E-mail:
STATE UBI #:
CITY OF EDMONDS BUSINESS LICENSE #:
WA STATE CONTRACTOR L & I #: (CCB) & EXPIRATION DATE:
Office Use Only
Permit #: i
TYPE OF PERMIT (Provide Details on Paae 2)
Accessory Structure/
Detached Garage
❑✓ Addition
Demolition
Mechanical
New Single Family/Duplex
F6/1 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:
Basement sq ft: Finishedl✓I Unfinished
1st Floor, so ft: 11469
I 2nd Floor, soft: 11240 1
I Garage/Carport; so ft: 1924
I Deck/Covered Porch/Patio: 1698 1
# of NEW Bedrooms:0 I # of NEW Bathrooms:0
Open Up the main floor moving the kitchen from
center to the north wall. Extending the
garage, extending laundry and bath into existing
o
covered porch. Deck addition on the back of the
house.
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 ownerto submit a permit application to the City of
Edmonds.
Print Name: Donald Jury 4 d
Signature:
GENERAL COMMERCIAL DATA
Occupancy Group(s): 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 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
MECHANICAL EQUIPMENT COUNTS (New and Relo"I �N
BTUs Gas / Elec / Other Qty
A/C Unit /Compressor Dec
Air Handler /VAV
Boiler
Dryer Duct .�
Exhaust Fans 4.
Fireplace
Furnace
Heat Pump Unit
Hydronic Heating
Roof Top Unit (Provide eleva-
tions if a Commercial Bldg)
Other:
Qty MY
Clothes Washer ,� Tub/Showers Z
Dishwasher 1 Back -flow Device (RPBA, DCDA, AVB)
Drinking Fountain Pressure Reduction/ Regulator Valve
Floor Drain/Sink Refrigerator Water Supply 1
Hose Bibs Water Heater -Tankless? Y or N Y
Hydronic Heat Water Service Line
Sinks 4 Other:
Toilets 3 Other:
BTUs Qty BTUs Qty
A/C Unit Outdoor BBQ/ Fire pit
Boiler Stove/Range/Oven
Dryer Water Heater
Fireplace/ Insert Other:
Furnace I I I Other:
Carbon Dioxide
Nitrous Oxide
Helium
Oxygen
Medical Air
Other:
Medical -Surgical Vacuum
Other:
Type of structure to be demolished:
Square footage of structure to be demolished: 581
AHERA Survey done?Y❑/N❑ PSCAA Case#:
Critical Areas Determination:
Study Required El Conditional Waiver[] Waiver❑
Fill in Place ❑ Fill Material
Removal ❑ Size of Tank (G7afiver
Critical Areas Determination:
Study Required Conditional Waiver
Grading: Cut 41.5 cubic yards
Fill cubic yards
Cut / Fill in Critical Area: Yes ❑ No
APPLICATIONS: Applications are valid for a maximum of 1 year.
ESLHA Applications, Z 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.