20160707090059.pdfOM1
City of Edmonds
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 ft Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, ity State, Zip):
Parcel #:
Subdivision/Lot #: IProject
Valuation: $ / ® Doo
APPLICANT: D_
Phone: Fax.
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. .�.Y
a 69 2,2 0
Address (Street, City, State Zip):
E- all Addres.:
l�-
�nle. a C
PRO TY OWNER: \
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
LENDING AGENCY:
Phone: Fax:
Address (Street, City, State, Zip):
E -Mail Address:
CONTRACTOR:
14
Phone: Fax:
7— 5f) 1 L 1371
Addres • Mreet, City State, Zip):
5 10A
E -Mail Address:
WA State License #/Ex . 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
Cit Business #/Exp. t1tt;:
�7
°Jitctse
DETAIL THE SCOPE OF WORK
_._..__ _.. ... ............ _ _ ,,, --------
PROPOSED NEW SQUARE FOOTAGE FOR THIS PROJECT:
Basement: „ _1O .sq. ft.
Select Basement T e: Finished Unfinished µwww
1" Floor: -....._ ...... _ .... _ s . ft.
Gara e/Car ort: s . ft.
2°d Floor: s . ft.
._
Deck/Cvrd Porch/Patio: .,.eeee _..._s . ft.
Bedrooms # Full-3/4Bath # Half -Bath #_. ...
Other. m..�.,�__,�..... � -_ ..w.� .....e, _ s . ft.
Fire S rinklers: Yes No
Retainin Wall: Yes No
Grading: Cut cu. yds. Fill cu.yds.
Cut/Fill in Critical Area: Yes m_IT„ No17
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 ant the property owner or duly authorized agent of the property owner to submit a permit application to
ids
City mon�a�m
Print Ni1�t'" ': i E_. -amµ. -..
Own eri�fAgenil(1ther ❑ (specify): .....
i tgattnc�—X
-- �..
Date �
FORM A L:\Building New Folder 2010\DONE & x-ferred to L -Building -New drive\Form A2014.docx Updated: 1/17/2014