20160513161220.pdfDEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
est. 1 121 5`b Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 4 Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): Parcel#:
'7AVEe 51 MON , W,
Subdivision/Lot #: Project Valuation: $
APPLICANT: Phone: Fax:
Address (Street, City, State, Zip):
-7 e
PROPERTY OWNER:
Address (Street, City, State, Zip):
LENDING AGENCY:
Address (Street, City, State, Zip):
CONTRACTOR:*
Address (Street, City, State, Zip):
20 o
E -Mail Address:
Phone: Fax:
E -Mail Address:
Phone: Fax:
E -Mail Address:
Phone: Fax:
E -Mail Address:
WA State License #/Exp. Date:
*Contractor must have a valid City of Edmonds business license prior to
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License#/Exp. Date:
AAl
DETAIL THE SCOPE OF WORK:
PROPOSED NEW SIIA
Basement: s . ft.
1$1 Floor:
7 Floor: sqft.
FOOTAGE FOR THIS PROJECT:
Select Basement Type: Finished LJ Unfinished
Gara e/C ort: sq. ft.
Deck/Cvrd Porch/Patio: _sq. ft.
Bedrooms # Full -3/4 Bath # Half -Bath # Other: S9. It.
Fire Sprinklers: Yes LJ No Retainin Wall: Yes No
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: ' k .. ®, Owner ixAgent/Other ❑ (specify):
Signature:
Date: 1 % �
FORINT A LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014
ED&O
N0THC'
E
TO PERMITTEE AND/OR OWNER
0 PARTIAL APPROVAL 1 CORRECTION REQUIRED El ENFORCEMENT VIOLATION
Owner Permit Number /6- OOJO;'
Job Address q--Itsr) Site Contact
Type of Inspection - -------
0 WORK DESCRIBED BELOW HAS BEEN INSPECTED AND APPROVED.
[3 APPROVED PLANS AND JOB CARD MUST BE AVAILABLE TO INSPECTOR ON SITE.
[3 CORRECTIONS LISTED BELOW MUST BE MADE BEFORE WORK CAN BE APPROVED
AND/OR THE NEXT PHASE OF WORK IS STARTED.
0 RECALL FOR INSPECTION.
[--] REINSPECTION FEE MUST BE PAID PRIOR TO NEXT INSPECTION REQUEST.
0 STOP WORK -UNTIL AUTHORIZED TO CONTINUE BY CITY INSPECTOR.
KA PQ/A1,6. 6v 1±111
I
THE ACTIONS OR CORRECTIONS INDICATED ABOVE ARE REQUIRED TO BE CORRECTED BY
(DATE) OR PENALTIES MAY BE APPLIED. FOR INSPECTION CALL 425-771-0220
Building 1:1 Planning 0 Engineering 11 Fire 1:1 Public Works
Inspector Date.
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THIS NOTICE TO REMAIN ON SITE
White: Permit File Buff: Applicant