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`a DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
' APPLICATION
to V `t 121 5`n Avenue N, Edmonds, WA 98020
City of Edmonds 1 Phone 425.771.0220!k Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip): f Parcel #:
Subdivision/Lot#: Project Valuation: $ 01 t6
APPLICANT: Phone: Fax;
Address(StreeI �a M", it Address:
PROPERTY OWNER„ Phty'le: Fax:
Address (Street City "mate, Zip) E -Mail Address„
.LENDING AGENCY: Phone: Fax:
ke
(Street, City, State, Zip): E -Mail Address;
CON CTO Is'"° ,m i Phone: Fax:
� ,.. (,)
Address (Street, City, State, Zip): E -Mail Address:
License lld6; tp. [fit
*Contractor must have a valid City of Edmonds business license prior to ti,,„State &J
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City I311ina ss
License rtst f, 1. 17 att
DETAIL THE SCOPE OF WORK:
.......
................ .—-------..........................
..... .. ........m "� �'” mow., �
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: s . ft, Select Basement T e: Finished U Unfinished171
I" Floor: s . ft. Gara e/Car ort: „wwww_ ... .,_,. S2. ft.
2" Floor: --..,sq. ft. Deck/Cvrd Porch/Patio: _...._ s . ft.
Bedrooms # Full -3/4 Bath # _ Half -Bath #_ Other: sq. ft.
Fire Sprinklers: Yes F1 No Retainin Wall: Yes No
Grading: Cut .......................... . .--cu. yds. Fill „m,—cu.yds. Cut/Fill in Critical Area: Yes 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:�7 Owner ❑ Agent/Other ❑ (specify):. a CJIr
..
60
r r
Signature: ��..� .t`��.�� � Date:
FORM A L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2011