20160502140407.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 A Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street. Syite # City State, Z' Parcel #:
C 1- N
Subdivision/Lot #: Project Valuation: $ ADZ
APPLICANT: Phone: 4125 Z l' Fax:
Address (Street, City, State„ Zip): E -Mail Address:
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PROPERTY OWNER: o Z6 Phone: Fax:
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Address (Street, ity, State, Zip)-�� 1 E -Mail Address:
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LENDING AGENCY: `f OL¢ Phone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* enr Phone:
Address (Street, City, Stade, Zip): E -Mail. Address:
S ro5
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to ZrcPw ^ r,00 1 2f4 Z
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK: .® f r� r v� ' n Ci " (f ev'!_�G7�
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: —sq, ft. Select Basement Type: Finished Lj Unfinished
1s1 Floor: s . ft. Gara e/C ort: S2. ft.
2nd Floor: _____,sq. ft. Deck/Cvrd Porch/Patio: s . ft.
Bedrooms # Full -3/4 Bath# Half -Bath # Other: sci. ft.
Fire S rinklers: Yes 0 Nol Retaining Wall: Yes 17 NoEl
Grading: Cut —cu. yds. Fill cu.yds. Cut/Fill in Critical Area: Yes LJ No
I declare under penalty of perjury laws 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:�e �r Owner ❑ Agent/Other ❑ (specify):
__Z C
Signature: Date: .�..
FORM A LABuilding New Folder 201000NE & x-ferred to 1 -Building -New drive\Form A2014.docx Updated: 1/17/2014